Handbook 

of 

Rectal  Diseases 


S.  H. 


M.    H 


_      1.  H 


A 


PLATE   I. 

THE  BLOOD  VESSELS  OF  THE  RECTUM. 

S.  H.  Superior    haemorrhoidal    artery.         M.    H.     Middle    haemorrhoidal 
artery.     L.  H.  Inferior  haemorrhoidal  artery.     A.  Anus.     E.  S.  External  sphinc- 
r  muscle.     P.  D.   Pelvic  diaphragm.      P.  Cut  edge  of  peritoneum. 

The  Kcctuni:  Its  Diseases  and   Developmental  Defects,  by  Sir  Charles  Ball. 


,UE  ' OF 

CGLLE'-  EGFATK 


LHand  Book 


OF 


Diseases  of  the  Rectum7 


BY 

LOUIS  J.  HIRSCHMAN,  M.  D. 

DETROIT,   MICHIGAN,   U.   S.   A. 

FELLOW  AMERICAN  PROCTOLOGIC  SOCIETY;  LECTURER  ON  RECTAL  SURGERY  AND 
CLINICAL  PROFESSOR  OF  PROCTOLOGY,   DETROIT   COLLEGE   OF   MEDICINE; 
ATTENDING  PROCTOLOGIST.  HARPER  HOSPITAL;  CONSULTING  GYNE- 
COLOGIST, DETROIT  GERMAN  POLYCLINIC;   COLLABORATOR  ON 
PROCTOLOGY,  "PHYSICIAN  AND  SURGEON";  EDITOR  "HAR- 
PER HOSPITAL  BULLETIN";  CHAIRMAN  SECTION  ON 
SURGERY,  MICHIGAN  STATE  MEDICAL  SOCI- 
ETY;   EX-PRESIDENT  ALUMNI  ASSOCI- 
ATION,   DETROIT    COLLEGE    OF 
MEDICINE,    ETC.,  ETC. 


WITH     ONE    HUNDRED    AND    FORTY-SEVEN      ILLUSTRATIONS, 

MOSTLY     ORIGINAL,     INCLUDING    TWO 

COLORED    PLATES. 


St.  Louis, 
C.  V.  MOSBY  MEDICAL  BOOK  &  PUBLISHING  CO. 

1909 


0  Yfl/AflSU       / 
BTcC  10  -303JJOO 


COPYRIGHTED  BY  C.  V.  MOSBY  Co.,  1909. 


TO  THE 

MEMORY  OF  MY  FATHER, 
FREDERICK  LOUIS  HIRSCHMAN,  M.  D., 

A  country  doctor  ivhose  untimely 
death  ivas  a  sacrifice  to  the  duties 
of  that  overworked  and  wholly 
unappreciated  class  of  our  pro- 
fession— the  Country  Doctor:  this 
zvork  is  affectionately  dedicated  by 
THE  AUTHOR 


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J 

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PREFACE 


In  presenting  this  book  to  the  medical  profession,  the 
author  does  so  with  the  feeling  that  it  will  be  of  some 
assistance  to  that  great  mass  who  were  as  unfortunate  as 
himself  in  their  early  college  training  in  the  special  field 
of  Proctology.  Diseases  of  the  Kectum  and  Anus  have 
been,  and  still  are,  in  a  great  many  colleges,  dismissed 
with  a  single  lecture  or  two,  delivered  as  a  part  of  the 
course  on  general  surgery.  The  young  graduate  in  medi- 
cine leaves  his  Alma  Mater  with  a  hazy  idea  that  occas- 
ionally patients  may  suffer  from  "Piles  or  Fistula," 
and  an  operation  under  general  anesthesia  is  their  only 
hope  of  relief. 

The  fact  that  the  profession  as  a  whole  has  been  so  re- 
miss in  the  treatment  of  patients  suffering  from  rectal 
diseases  has  left  the  field  in  the  past  to  the  quack  and 
the  irregular. 

A  few  earnest  practitioners,  however,  in  different  parts 
of  the  country,  gradually  discovered  that  there  was  some- 
thing more  to  rectal  diseases  than  the  treatment  of  "Piles 
and  Fistula,"  and  commenced  the  scientific  study  of  the 
lower  bowel  with  the  result,  that  today  the  special  field  of 
Proctology  is  firmly  established  with  conscientious  work- 
ers in  all  parts  of  the  world.  The  results  of  the  work  of 
some  of  these  men  have  been  given  to  the  world  in  the 
shape  of  most  complete  text-books  on  the  subject.  In 


6  PREFACE. 

many  of  these  works,  however,  the  subject  has  been 
treated  from  the  standpoint  of  the  specialist  in  rectal  dis- 
eases, and  written  for  those  who  wish  to  follow  that  line 
of  work. 

With  the  introduction  of  local  anesthesia  into  the  treat- 
ment of  diseases  of  the  Rectum  and  Anus,  a  new  field 
of  work  has  been  opened.  Those  patients  suffering  from 
many  diseases  of  this  region,  who  have  sought  the  advice 
and  care  of  the  irregular  and  the  advertising  quack,  have 
done  so  on  account  of  their  dread  of  hospitals,  general 
anesthesia  and  "the  knife." 

In  order  that  the  general  practitioner  may  be  qualified 
to  diagnose  and  treat  his  patient  suffering  from  ano-rec- 
tal  diseases,  as  scientifically  and  as  successfully  as  he 
does  affections  of  other  organs  and  localities,  the  author 
presents  the  results  of  his  experiences  in  the  treatment 
of  ano-rectal  disease. 

The  diagnosis  of  disease  originating  in  this  region,  has 
been  dwelt  upon  to  emphasize  the  importance  of  early 
examination.  Illustrations,  for  the  most  part  original, 
have  been  used  wherever  it  has  been  thought  necessary  to 
supplement  the  text  for  the  sake  of  clearness. 

Non-surgical  methods  are  described  in  those  conditions 
where  they  have  been  found  of  value,  and  the  technique 
of  operative  measures  under  local  anesthesia  been  made 
as  simple  as  possible.  Only  those  conditions  which  are 
amenable  to  treatment  in  office'  practice  have  been  dis- 
cussed, and  the  limitations  of  office  treatment  clearly  set 
forth.  For  information  regarding  those  operative  meas- 
ures which  are  only  applicable  under  general  anesthesia, 
and  the  consideration  of  those  diseases  whose  treatment 
requires  confinement  to  bed,  the  reader  is  referred  to  the 


PEEFACE.  7 

several  complete  works  on  proctology  which  are  now 
available. 

Those  physicians  living  and  practicing  in  the  Southern 
states,  particularly,  will  appreciate  the  inclusion  in  this 
work  of  a  chapter  on  Dysentery.  The  author  has  been 
exceedingly  fortunate  in  securing  the  services  of  a  man 
to  prepare  this  chapter,  than  whom  there  is  no  one  better 
posted  on  the  subject:  Dr.  John  L.  Jelks,  of  Memphis, 
Tenn.,  Vice-President  of  the  American  Proctologic  So- 
ciety. 

Inasmuch  as  a  very  important  index  to  the  condition 
of  the  entire  digestive  tract  and  its  functions  is  found  in 
the  excretions;  and  the  fact  that  the  examination  of  the 
stools  which  is  fully  as  important  as  the  urinary  analysis, 
has  been  too  long  neglected ;  a  chapter  on  the  examination 
of  the  feces  has  also  been  included.  Dr.  George  W.  Wag- 
ner, of  Detroit,  Attending  Physician  to  Harper  Hospital, 
Gastro-Enterologist  to  the  German  Polyclinic  and  Clini- 
cal Professor  of  Medicine  in  the  Detroit  College  of  Medi- 
cine, has  kindly  contributed  this  chapter,  and  the  author 
considers  himself  extremely  fortunate  in  securing  the 
assistance  of  so  well  qualified  a  man. 

To  the  above  named  gentlemen ;  to  Dr.  Robert  C.  Jamie- 
son,  of  Detroit,  Dermatologist  to  Harper  Hospital  Poly- 
clinic,  who  made  the  excellent  photographs  under  the 
author's  direction;  to  Mr.  James  T.  Nolan,  the  artist  of 
Western  Reserve  University  Medical  Department,  of 
Cleveland,  O.,  who  made  all  of  the  drawings;  to  the  J. 
P.  Hartz  Co.,  of  Detroit,  who  furnished  the  illustrations 
of  many  of  the  surgical  instruments;  to  the  publishers 
for  their  hearty  and  willing  co-operation ;  and  lastly,  to 
the  many  members  of  the  medical  profession  through 


8  PREFACE. 

whose  courtesy  the  author  has  been  able  to  treat  the  large 
number  of  cases,  the  results  of  his  experience  with  which 
has  furnished  the  basis  for  the  preparation  of  this  work 
— the  author  extends  his  sincere  and  heartfelt  thanks. 

Besides  the  results  of  his  own  experience,  the  author 
has  availed  himself  of  the  privilege  of  consulting  many 
of  the  recent  works  and  text-books  on  the  subject  of 
proctology,  among  which  may  be  mentioned  those  of  Tut- 
tle,  Gant,  Matthews,  Martin,  Ball,  Cripps,  Wallis  and 
Gray,  as  well  as  many  articles  by  other  authors  appearing 
in  the  current  literature  of  the  day. 

If  the  author  has  succeeded  in  so  simplifying  the  diag- 
nosis and  treatment  of  many  of  the  more  common  diseases 
of  the  Rectum  and  Anus  so  that  this  work  will  be  of  some 
assistance  to  the  busy  general  practitioner,  in  his  every 
day  work;  and  has  assisted  in  even  a  small  degree  in 
broadening  the  scope  of  the  use  of  local  anesthesia  in  this 
field,  he  will  feel  that  he  has  accomplished  all  that  he  set 
out  to  do.  This  modest  work  does  not  pretend  or  aspire 
to  take  the  place  of  a  text-book  on  the  whole  subject  of 
proctology,  but  if  it  will  find  a  place  on  the  physician's 
desk  as  a  working  hand  book,  the  author  feels- that  it  will 
fill  a  long  felt  want. 

Louis  J.  HIBSCHMAN. 
604  Washington  Arcade. 
Detroit,  Jan.  11,  1909. 


TABLE  OF  CONTENTS 


PREFACE     5-8 

CHAPTER  I. 
ANATOMY. 

The  Anus — Anal  Canal — External  Sphincter  Muscle — Anal  Papillae 
Crypts  of  Morgagni — Rectum — Internal  Sphincter  Muscle — Col- 
umns of  Morgagni — Rectal  Valves — Levator  Ani  Muscle — Ilio- 
Coccygeus  —  Pubo-Coccygeus  —  Pubo-Rectalis  —  Ligaments — 
Ano-Coccygeal  and  Lateral — Relations  of  the  Rectum — Iscliio- 
Rectal  Fossa — Sigmoid  Colon — Blood  Supply — Arterial,  Venous 
— Lymphatics — Nerve  Supply 17-32 

CHAPTER   II. 
SYMPTOMS  WHICH  SHOULD  CALL  ATTENTION  TO  THE  RECTUM. 

Pain  —  Tenderness  —  Spasm  —  Bleeding  —  Itching  —  Protrusions 
— Ulcerations  —  Discharge  —  Constipation  —  Diarrhoea  —  Al- 
tered Stools — Sacral  Backache — Shooting  Pains  down  the  Limbs 
— Crampy,  Painful  and  Scanty  Menstruation — Frequent  and 
Painful  Urination — Loss  of  Appetite — Impaired  Digestion — 
Nausea — Headache — Sallow  Complexion  -  -  Fever — Anemia — 
Restlessness  in  Children — Foreign  Bodies 33-40 

CHAPTER  III. 
EXAMINATION  OF  THE  PATIENT. 

The  physician's  offices — Operating  room  equipment — Preparation  for 
examination — Interrogation  of  patient — Record  keeping — /Sims' 
position — Ocular  inspection — Digital  examination — Position  of 
patient,  correct  and  incorrect — Vagino-rectal  examination — 
Eversion  of  anus — Lithotomy  position — Bimanual  abdomino- 
vaginal  and  abdomino-rectal  examination — Squatting  position 
Internal  inspection — Knee-shoulder  position — Correct  and  in- 
correct methods — Anoscopy — Necessary  instruments  and  appli- 
ances— Technique  of  proctoscopy  without  instruments — Instru- 
mental proctoscopy — Necessary  instruments  and  appliances — 
Exaggerated  Lithotomy  position — Sigmoidoscopy — Necessary 
instruments — Congenital  defects  and  mal-formations 41-76 


10  TABLE   OF  CONTENTS. 

CHAPTER  IV. 
CONSTIPATION  AND  OBSTIPATION. 

Differentiation  of  two  conditions — Physiology  of  defecation — Eti- 
ology of  Constipation — Methods  of  examination — Diagnosis  and 
treatment  — Dietary  — Exercise  — Mechanical  therapeutics — Au- 
thor's method — Internal  Medication — Obstipation — The  rectal 
valves — Rectal  valvotomy — Author's  technique  77-96 

CHAPTER  V. 
FECAL  IMPACTION. 

Etiology — Symptoms — Diagnosis — Treatment — Palliative  and  radi- 
cal   97-101 

CHAPTER  VI. 
PRURITUS  ANI. 

Etiology — Local  causes  — Skin  diseases —  Reflex —  Constitutional — 
Dietary — Parasitic — Irritation — Examination  of  patient — Diag- 
nosis— Treatment — Palliative  and  medicinal — Mechanical — Sur- 
gical— Hamilton's  operation — Balls  operation — Author's  tech- 
nique under  local  anesthesia 102-121 

CHAPTER  VII. 
ANAL  FISSURE  AND  ULCER. 

Etiology — Location — Sentinel  Pile — Diagnosis — Methods  of  exami- 
nation— Treatment — Palliative  — Non-Surgical — Surgical  Treat- 
ment— Incision — Divulsion  of  sphincter — Excision — Author's  op- 
eration— Anal  ulcer — Treatment — After  care 122-136 

CHAPTER  VII. 
ABSCESS  OF  THE  ANO-RECTAL  REGION. 

Predisposing  causes — Etiology — Tegumentary  Abscess — Diagnosis — 
Treatment — Subtegumentary  or  marginal  abscess — Symptoms — 
Methods  of  Examination — Sub-mucous  abscess — Examination — 
Diagnosis  — Treatment  — Operative  Technique —  After  Care  — 
Ischio-rectal  abscess — Etiology  —  Symptoms  —  Examination — 
Diagnosis — Treatment — After  care — Caution  137-151 

CHAPTER  IX. 
FISTULA   IN  ANO. 

Etiology — Varieties — Simple,  horseshoe  and  multiple  fistulae — 
Blind,  internal  and  external  fistulae — Submucous  fistulae — 
Simple  complete  fistulae — Symptoms — Examination  and  diag- 
nostic methods — Treatment  —  Incision  —  Excision  —  Author's 
technique — Ligature  operation — After  care — Blind  external  fis- 
tulae— Examination,  diagnosis  and  treatment — Blind  internal 
fistulae — Symptoms  —  Examination — Diagnosis  —  Treatment — 
After  care — Submucous  tract — Mucocutaneous  fistula — Bismuth 

injection Technique — Fistula  in   ano  in   the  Tuberculous — 

Symptoms — Diagnosis — Treatment     152-172 


TABLE   OF  CONTENTS.  11 

CHAPTER  X. 
HEMORRHOIDS. 

Neglect  on  the  part  of  medical  profession — Incomplete  training  of 
medical  students  in  proctology — Varieties  of  hemorrhoids — 
Etiology — Anatomical — Habit — Occupation — Abuse  of  cathar- 
tics— Symptoms — Hemorrhage — Pain  —  Protrusion — Diagnosis 
and  technique  of  examination — Position  of  patient — Instru- 
ments required — Differential  diagnosis — Treatment — Palliative 
Injection  treatment  —  Cauterization  —  Operative  treatment — 
Technique — Author's  bloodless  operation — Instruments  and 
technique — After  care — Incision — Acute  thrombotic  hemorrh- 
oids  Technique  of  operation — External  integumentary  hem- 
orrhoids— Operative  technique — After  care — Caution 173-208 

CHAPTER  XI. 

RECTAL  POLYPI,   HYPERTROPHIED   ANAL   PAPILLAE, 
CRYPTITIS. 

Polypi — Varieties — Symptoms — Diagnosis — Treatment — Anal  papil- 
lae— Description  — Etiology —  Examination — Diagnosis — Symp- 
toms— Cryptitis  —  Etiology  —  Diagnosis  —  Symptoms  —  Treat- 
ment   209-220 

CHAPTER  XII. 
PROCTITIS  AND  SIGMOIDITIS. 

Acute  Proctitis— Etiology — Symptoms — Diagnosis — Method  of  exam- 
ination— Treatment — Dietary — Systemic- — Local — Posture  of  pa- 
tient— Apparatus  required — Internal  medication — Chronic  proc- 
titis  and  sigmoiditis — Hypertrophic  and  atrophic — Hypertro- 
phic — Etiology — Symptoms — Diagnosis — Treatment  —  Chronic 
atrophic  proctitis  and  sigmoiditis — Pathology — Symptoms — 
Treatment  221-237 

CHAPTER  XIII. 

DYSENTERY. 

Historical — Geographical  distribution — General  etiology — Season — 
Race — Sex — Hygiene — Topography  and  condition  of  soil — Foods 

— Drinking  water Classification — Acute  catarrhal  dysentery 

— Special  etiology — Pathology — Symptoms  —  Diagnosis — Prog- 
nosis —  Diphtheritic  dysentery  —  Etiology— Pathology — Symp- 
toms— Diagnosis — Complications — Secondary  Diphtheritic  Dys- 
entery— Symptoms — Prognosis — Amoebic  dysentery — Etiology 
— The  Amoeba  dysenteriae — Pathology— Symptoms — Complica- 
tions and  Sequelae — Diagnosis — Prognosis — Treatment — Pro- 
phylaxis— Diet — Remedies — Irrigations — Technique — Local  Ap- 
plications— Technique — Appendicostomy — Valvotomy  238-283 

CHAPTER   XIV. 

PROLAPSE  OF  THE  RECTUM  IN  CHILDREN. 
Degrees    of   prolapse — Etiology — Symptoms — Diagnosis — Treatment 
— Palliative — Prophylactic — Dietary — Concealed      prolapse — De- 
scription— Education  of  mothers — Palliative  treatment — Cauter- 
ization— Technique  of  operation — After  care 284-294 


12  TABLE  OF  CONTENTS. 

CHAPTER  XV. 

THE  TECHNIQUE  OF  THE  USE  OF  LOCAL  ANESTHESIA  IN  THE 
TREATMENT  OF  ANO-RECTAL  DISEASES. 

Field  of  local  anesthesia— Anesthetic  agents— Technique  of  prepara- 
tion— Instruments  and  apparatus  required — Preparation  of  pa- 
tient— Posture — Technique  of  anesthetization — Caution — Ex- 
ternal hemorrhoids— Acute  thrombotic  hemorrhoids— Peri-anal 
abscess — Fissure  in  ano— Fistula  in  ano— Hypertrophied  anal 
papilla— hypertrophied  rectal  valves— Removal  of  foreign  bodies 
—Removal  of  peri-anal  benign  growths— Posterior  internal 
proctotomy — Caution  295-311 

CHAPTER  XVI. 

THE  LIMITATIONS  OF  OFFICE  TREATMENT  AND  INDICATIONS 
FOR  OTHER  MEASURES. 

Limitations  of  local  anesthesia  in  rectal  surgery—Necessity  for  care- 
ful and  complete  examination — History  of  concurrent  disease, 
Anemia  and  hemophilia — Malignancy — Syphilis — Tuberculosis 
and  Hysteria — Early  diagnosis  of  malignant  disease — Symp- 
toms of  beginning  cancer — Ulceration  of  the  bowel — Colostomy 
— Stricture  of  the  rectum — Nitrous  oxide — Circum-anal  and 
peri-rectal  abscess— Fistula  in  ano— Hemorrhoids— Prolapse  of 
the  rectum — Removal  of  concretions  or  foreign  bodies — Fistula 
between  rectum  and  other  organs 312-325 

CHAPTER  XVII. 
THE  FECES  AND  THEIR  EXAMINATION. 

Normal  stool — Duration  of  passage — Amount,  consistency  and 
form — Odor — Color — Macroscopic  elements — Clinical  examina- 
tion of  the  stool — Normal  constituents — Pathological  constitu- 
ents— Chemical  examination — Reaction — Tests — Estimation  of 
albumin  residue — Clinical  significance  of  tests — Mucus — Bili- 
rubin — Semi-digested  cells — Hyaline  cells — Bile  pigment — Fat 
— Remnants  of  meat — Excess  of  connective  tissue,  undigested 
muscle  fibre — Pathologic  carbohydrate  fermentation  and  albu- 
min fermentation — Pus — Blood — Various  .tests — Gall-stones — 
Intestinal  concretions — Intestinal  sand — Animal  parasites — 
Protozoa — Worms — Varieties — Character  of  feces  in  certain  in- 
testinal infections — Acute  intestinal  catarrh — Chronic  inflam- 
mation of  the  intestines — Diphtheritic  enteritis — Muco-Mem- 
branous  colitis — Cholera  Nostras — Dysentery — Amoebic  dysen- 
tery—Carcinoma   326-363 

INDEX  ..365 


LIST  OF  ILLUSTRATIONS 


PLATE  I.     Blood  Vessels  of  the  Rectum Frontispiece 

Figure.  Page. 

1.  Rectum  and  Anal  Canal  in  the  Male 19 

2.  Rectum  Hardened  in  Formalin 21 

3.  Proctoscopic  View  of  Rectal  Valves 23 

4.  Muscles  and  Nerves  of  Male  Pelvic  Outlet 25 

5.  Columbus  Operatng  Table 43 

6.  Simple  Form  of  Sterilizer  for  Office  Use 44 

7.  Small  Instrument  and  Dressing  Sterilizer 44 

8.  Characteristic  Sitting  Posture  in  Ano-Rectal  Disease 45 

9.  Quadrants  of  the  Anus 46 

10.  Author's   Record    Card 47 

11.  Reverse  Side  of  Record  Card 48 

12.  External  Inspection  40 

13.  Electric  Headlight 49 

14      Application  of  Lubricant  from  Collapsible  Tube 50 

15.  Incorrect  Method  of  Digital  Examination 51 

16.  Correct  Method  of  Digital  Examination 52 

17.  Vaginal  Eversion  of  Anus 54 

18.  Another  Method  of  Everting  Anus 55 

19.  Amount  of  Possible  Eversion  of  Anal  Tissues 58 

20.  Recto-Abdominal  Bimanual    Palpation 57 

21.  Method  of  Recto-Abdominal   Palpation 57 

22.  Palpation  of  Rectum  Through  Posterior  Vaginal  Wall 58 

23.  Method  of  Examining  the  Coccyx 59 

24.  Ischio-Rectal  Abscess   60 

25.  Squatting  Position  61 

26.  Rubber  Bulb  Syringe 62 

27.  Method  of  Using  Author's  Fenestrated  Anoscope 62 

28.  Knee — Elbow    Position 63 

29.  Knee — Shoulder  Position    64 

30.  Author's  Anoscope  with  Oblique  Opening 65 

31.  Author's  Adjustable  Fenestrated  Anoscope 66 

32.  Silver  Probe  66 

13 


14  LIST  OF  ILLUSTRATIONS. 

33.  Long  Alligator  Forceps 67 

34.  Kelly  Anoscope 67 

35.  Bivalve  Rectal  Speculum 68 

36.  Wales  Rectal  Bougie 69 

37.  Author's  Modification  of  Martin  Proctoscope 70 

38.  Exaggerated  Lithotomy  Position 72 

39.  Kelly  Sigmoidoscope  73 

40.  Sigmoidoscope  with  Author's  Tilting  Obturator 73 

41.  Atresia  Ani  Vaginalis  (complete) 74 

42.  Atresia  Ani  Vaginalis   (incomplete) 75 

43.  Author's  Dilating  Rectal  Massage  Bag 80 

44.  Author's  Rectal  Massage  Bag  (inflated  and  deflated) 87 

45.  Position  for  Author's  Method  of  Rectal  Massage 88 

46.  Author's  Four-Inch  Operating  Proctoscope 92, 

47.  Author's  Valvotomy  Needle 93 

48.  Author's  Angular  Rectal  Scissors 94 

49.  Technique  of  Author's  Operation  for  Rectal  Valvotomy 94 

50.  Proctoscopic  View  of  Author's  Valvotomy  Operation 95 

51.  Pruritus  Ani 105 

52.  External  Hemorrhoids  with  Pruritus  Ani 106 

53.  A  Simple  Rectal  Dressing ' 113 

54.  Sharp  Pointed  Scissors,  Curved  on  the  Flat 11 4 

55.  T-Forceps   . : 117 

56.  Lines  for  Incision  in  Ball's  Operation 118 

57.  Dissection  of  Flap — Ball's  Operation 119 

58.  Area  of  Anesthesia 120 

59.  Fissure  of  the  Anus 122 

60.  Multiple  Fissure  in  Ano 123 

Cl.     Fissure  in  Ano  from   Crypt  of  Morgagni 125 

62.  Applying  Ointment   to    Anus  from  Lead  Tube 128 

63.  Incision  of  Fissure 131 

64.  Sharp  Toothed  Forceps 133 

65.  Author's  Technique  for  Excision  of  Anal  Fissure 134 

66.  Operation  for  Excision  of  Anal  Ulcer 135 

67.  Ano-Rectal  Abscesses 139 

68.  Proctoscopic  View  of  Submucous  Abscess 143 

69.  De  Vilbiss  Rectal  Speculum 145 

70.  Incision  for  Opening  Ischio-Rectal  Abscess 148 

71.  Ano-Rectal  Fisttilae 155 

72.  Direct  Complete  Fistula  in  Ano 156 

73.  Angular  Fistulous  Tract 157 

74.  Grooved  Director   . . .  '. 15S 

75.  Right-Angled  Incision  for   Fistula  in  Ano 160 


LIST  OF  ILLUSTRATIONS.  15 

76.  Author's  Technique  for  Excision  of  Fistulous   Tract 161 

77.  (a)  Technique  of  Ligature  Operation  for  Fistula 163 

78.  (b)   Constriction  Produced  by  Ligature 165 

79.  Acute  External  Thrombotic  Hemorrhoids 17G 

80.  External  Thrombotic  Hemorrhoids 177 

81.  External   Cutaneous   Hemorrhoids 17S 

82.  Interno-External  Hemorrhoids   179 

S3.     Section  of  Interno-External  Hemorrhoids 180 

84.  Interno-External  Hemorrhoids,  Injected 182 

85.  Prolapsing  Internal  Hemorrhoids 183 

86.  Method  of  Injecting  Prolapsing  Internal  Hemorrhoids 195 

87.  Author's  Hemorhoidal   Forceps 196 

88.  Rectal  Retractor    197 

89.  Author's  Blunt  Ligature  Carrier 198 

90.  Technique  of  Author's  Bloodless  Hemorrhoid  Operation. ... .  .190 

91.  Distension  of  External  Hemorhoid 20G 

92.  Rectal  Polypus    210 

93.  Section  of  Anal  Canal,  Showing  Hypertrophied  Papillae 213 

94.  Hypertrophied  Anal  Papillae 215 

95.  Proctoscopic  View  Hypertrophied  Anal  Papillae 216 

96.  Spraying  Rectum  in  Knee-Shoulder  Position 225 

97.  Author's  Rectal  Spray  Tube 226 

98.  De  Vilbiss  Spray  Tube 227 

99.  Ulcer  of  the  Rectum 233 

100.  Amoeba  Cell    249 

101.  Amoeba  Histolytica  Schaud .250 

102.  Slough  of  Mucous  Membrane  from  Fatal  Case 254 

103.  Edge  of  Intestinal  Ulcer 256 

104.  Dysenteric  Ulceration  on  Valves  of  Houston 257 

PLATE  II.     Section  of  Intestine  Below  Ulceration,  Opp 258 

105.  Instruments  for  Office  Treatment  of  Dysentery 272 

106.  Jelk's  Soft  Rubber  Recurrent  Irrigating  Tube 274 

107.  Exaggerated  Sim's  Position  for  Colon  Irrigation 276 

108.  Position  for  Introduction  of  Colon  Tube  Through  Proctoscope  278 

109.  Method  of  Making  Local  Applications  to  Rectum 280 

110.  Method  of  Spraying  Rectum  and  Sigmoid 281 

111.  Prolapse  of  Rectum — Third  Degree 285 

112.  Cauterization  of  Prolapse  of  Rectum — First  Degree 292 

1 13.  Aseptic  All-Glass   Hypodermatic   Syringe 297 

114.  Aseptic  All-Metal   Syringe   with  Extension 298 

115.  Point  of  Puncture  for  Injecting  Local  Anesthetic 300 

116.  Amount  of  Distension  of  Tissues   for  Local  Anesthesia 301 

117.  Dilating  Sphincter  with  Mechanical  Vibrator 302 


16  LIST  OF  ILLUSTRATIONS. 

118.  Amount  of  Dilatation  Under  Local  Anesthesia 303 

119.  Author's  Modification  of  Martin  Operating  Proctoscope 308 

120.  Cancer  of  Rectum  with  Multiple  Fistulae 31,1 

121.  Proctoscopic  View  of  Rectal  Carcinoma 317 

122.  Carcinoma,  Specimen  Shown  in  Preceding 318 

123.  Cancer  of  the  Rectum 319 

124.  Cancer  of  the  Rectum — Interior  View 320 

125.  Bismuth  Sulphide  Crystals  from  Stools 320 

126.  Collective  View  of  the  Feces 330 

127.  Muscle    Remnants    in    Feces 334 

11'8.  Hematoidin  Crystals   from  Acholic   Stools 334 

129.  Acholic   Stools 335 

130.  Steele's  Modification  of  Strasburger  Fermentation  Apparatus. 337 

131.  Mucus  Shreds 339 

132.  Mucus  Shreds  after  Addition  of  Acetic  Acid 340 

1 33.  Gallstones  345 

134.  The   Amoeba    Coli    347 

125.  Balantidium  Coli 348 

136.  Ascaris  Lumbricoides   349 

137.  Oxyuris  Vermicularis    350 

1 38.  Oxyuris  Vermicularis   35 1 

139.  Anchylostoma    Duodenale     352 

140.  Trichocephalus    Dispar    355 

1 41.  Trichinae    355 

1 42.  Anguillula  Stercoralis  357 

143.  Head  of  Taenia  Solium 355 

1 44.  Taenia  Saginata   359 

145.  Head  of  Bothriocephalus  Latus .360 


CHAPTER  I 

ANATOMY. 

It  is  not  the  intention  in  a  work  of  this  scope  to  go  into 
minor  anatomical  details  in  the  description  of  the  Anus 
and  Rectum.  It  is  essential,  however,  that  one  who  in- 
tends to  treat  even  the  more  common  and  uncomplicated 
diseases  of  the  Anus  and  Rectum  should  have  a  practical 
working  knowledge  of  the  gross  anatomy  of  the  ano-rec- 
tal  region. 

In  reversing  the  usual  order  of  describing  these  organs, 
the  author  starts  with  the  Anus  first  because  it  is  to  the 
anal  orifice  that  one's  attention  is  first  directed  in  pro 
ceeding  to  examine  or  operate  for  diseased  conditions 
affecting  these  organs.  It  appears  to  the  author,  there- 
fore, that  the  anatomy  of  these  organs  should  be  de- 
scribed in  the  order  in  which  they  are  met  with:  from 
without,  inward. 

The  Anus.  The  Anus  is  an  oval  aperture,  longitudin- 
al when  in  repose,  situated  at  a  point  equidistant  from 
the  tuberosities  of  the  ischii ;  and  about  one  inch  anterior 
to  the  tip  of  the  coccyx.  In  the  female  it  is  situated  a 
little  more  anteriorly  than  in  the  male.  The  anus  is 
surrounded  by  integument  which  is  colored  slightly  dark- 
er than  the  surrounding  skin.  The  skin  around  the  anus 
is  arranged  in  radiating  folds  caused  by  the  contraction 

17 


18  THE  ANAL  CANAL. 

of  the  corrugator  cutis  ani  muscle.  The  circum-anal  in- 
tegument contains  sweat  glands,  sebaceous  glands  and 
hair  follicles.  The  circumference  of  the  anal  orifice 
varies  from  an  inch  to  an  inch  and  three  quarters,  but 
it  may  be  dilated  to  a  circumference  five  or  six  times 
greater. 

The  Anal  Canal.  The  Anal  Canal  extends  from  the 
point  at  which  the  sides  of  the  anal  aperture  first  ap- 
pose  to  the  linea  dentata  or  lower  edges  of  the  semilunar 
valves,  which  guard  the  openings  to  the  crypts  of  Mor- 
gagni.  Its  depth  varies  from  two-thirds  to  an  inch  and 
a  quarter.  It  is  lined  by  a  membrane  composed  of  thin 
transitional  epithelium  gradually  changing  in  histologi- 
cal  formation  from  the  stratified  cells  of  true  skin  at 
the  anus,  to  the  goblet  cells  of  mucous  membrane  at  its 
juncture  with  the  rectum  at  the  linea  dentata  or  ano- 
rectal  line.  Surrounding  the  lining  membrane  is  one  of 
cellular  tissue,  and  beneath  this  the  muscular  layer  com- 
posed of  the  external  sphincter,  a  few  fibres  of  the  leva- 
tor  ani,  and  the  lower  portion  of  the  internal  sphincter. 
The  dimensions  of  the  anal  canal,  when  in  repose  or  di- 
lated is  slightly  smaller  than  that  of  the  anus  itself  in 
like  condition.  The  lining  membrane  presents  to  the  eye 
a  pinkish  red  shining  appearance;  in  some  cases  a  more 
or  less  purplish  hue. 

The  external  sphincter  muscle  is  the  most  important 
muscle  with  which  we  have  to  deal  from  a  surgical  point 
of  view,  and  is  the  principal  muscular  structure  which 
goes  to  form  the  anal  canal.  It  is  composed  of  circular 
and  longitudinal  fibres.  The  longitudinal  arise  from  the 
lower  end  and  posterior  aspect  of  the  coccyx  and  sur- 
rounding the  anus  in  an  elliptical  manner  meet  and  are 


19 


n  rm 

B.C.    /         III      • 

B.    /     '  ';    ! 


p. 


H.U.  ; 

8.V.  : 

8.1. 


P.R. 


Fig.  1. 
The  Rectum  and  Anal  Canal  in  the  Male — Longitudinal  Section. 

Section  made  by   Professor  A.   F.   Dixon  of  a  formalin  hardened 

male  pelvis. 

B.  C.      Bulbo-cavernosus  muscle. 
B.  Bladder. 

P.  Prostate  gland. 

R.  U.       Recto-urethralis   muscle. 

5".  V.      Seminal  vesicle  with  ejaculatory   duct  below. 
S.  I.        Internal    sphincter   muscle. 
S.  E.       External    sphincter   muscle. 
A.  Anus. 

P.  R.       Pubo-rectalis    muscle    round    which    the    rectum    bends    sharply 

to  be   continued  into  the  anal  canal. 
R.  Rectum. 

—The    Rectum;    Its   Diseases   and    Developmental    Defects, 
By    Sir    Charles   Ball. 


20      EXTERNAL  SPHINCTER MORGAGNIAN  CRYPTS. 

inserted  into  the  central  tendon  of  the  perineum.  The 
circular  fibres  are  more  superficial,  entirely  surrounding 
the  anal  canal.  The  muscle  is  normally  in  a  state  of 
contraction,  keeping  the  anus  closed  and  it  is  of  great 
importance  in  the  voluntary  control  of  the  act  of  defeca- 
tion. Its  nerve  supply  is  derived  from  the  third  and 
fourth  sacral  and  superficial  branch  of  the  internal  pudic 
and  a  filament  of  the  fifth  and  sixth  sacral  known  as  the 
lesser  sphincterian  nerve.  This  nerve  is  of  extreme  im- 
portance in  the  production  of  local  anesthesia  for  the 
dilatation  of  the  anus.  It  enters  the  external  sphincter 
on  either  side  at  a  point  at  the  juncture  of  the  lower  and 
middle  third  of  the  anus. 

At  the  upper  limit  of  the  anal  canal  at  its  juncture 
with  the  lower  portion  of  the  rectum  are  situated  the 
anal  papillae  and  erupts  of  Morgagni.  The  papillae  ap- 
pear as  a  more  or  less  distinct  line  of  small  saw-tooth 
like  triangular  projections  which  encircle  the  anal  canal. 
This  line  is  called  the  linea  dentata,  or  ano-rectal  line 
Just  behind  these  papillae  are  found  the  openings  of  the 
crypts  of  Morgagni.  The  anal  papillae  and  crypts  of 
Morgagni  are  of  especial  interest  because  they  are  often 
the  seat  of  inflammatory  conditions  which  present  symp- 
toms often  out  of  all  proportion  to  the  size  of  the  lesion 
causing  them. 

The  blood  and  lymphatic  supply  will  be  taken  up 
later. 

The  Rectum.  The  Rectum  is  a  hollow,  tubular  organ 
varying  in  length  from  five  to  seven  inches,  and  extend- 
ing upward  from  the  ano-rectal  line  to  the  recto-sigmoid- 
al  juncture.  When  empty,  its  anterior  and  posterior 
walls  appose  and  a  cross-section  would  show  a  trans- 


21 


Fig.  2. 
Rectum  Hardened  in  Situ  With  Formalin  and  Then  Dissected  Out. 

S.  Sacral   curve   of   rectum. 

P.  Peritoneum  cut  at  reflexion   from  bowel. 

R.  Portion   of   rectum  uncovered  by  peritoneum. 

D.  Pelvic    diaphragm. 

E.  External    sphincter. 

— The    Rectum ;    Its   Diseases   and    Developmental    Defects, 
Bv    Sir   Charles   Ball. 


22  THE  RECTUM. 

verse  slit.  The  rectum  is  usually  understood  to  be  that 
portion  of  the  lower  end  of  the  large  intestine  which  ex- 
tends from  the  left  sacro-iliac  symphysis  to  the  ano-rectal 
line.  Instead  of  it  being  a  straight  canal  as  its  name 
indicates,  it  is  curved  backward  from  the  ano-rectal  line, 
following  the  hollow  of  the  sacrum,  curving  forward  at 
the  promontory,  where  it  joins  the  lower  portion  of  the 
sigmoid  flexure.  Some  authors  describe  the  rectum  as 
that  portion  which  extends  from  the  ano-rectal  line  to 
the  third  sacral  vertebra,  which  includes  that  portion 
which  is  not  covered  by  peritoneum ;  the  part  above  this 
being  called  the  lower  end  of  the  pelvic  colon  or  sigmoid 
colon.  Inasmuch  as  this  latter  division  has  not  been 
accepted  as  yet,  the  author  will  consider  the  rectum  as 
described  in  all  of  the  standard  text-books  on  anatomy. 
We  will  consider  the  rectum  as  divided  in  two  portions, 
the  upper  or  peritoneal  portion;  and  the  lower  or  that 
portion  below  the  third  sacral  vertebra,  the  extra-peri- 
toneal. Thomas  Charles  Martin  divides  the  rectal  cavity 
into  first,  second  and  third  rectal  chambers,  each  cham- 
ber corresponding  to  that  portion  below  one  of  the  rec- 
tal valves  or  folds  of  Houston. 

The  rectum  is  composed  of  four  coats,  being  from  with- 
in outward:  the  mucous,  submucous,  muscular  and  ser- 
ous. The  muscular  coat  is  composed  of  both  circular 
and  longitudinal  fibres.  At  the  lower  portion  of  the 
rectum  and  extending  down  to  the  white  line  of  Hilton 
in  the  anal  canal,  the  circular  muscular  fibres  are  more 
numerous  and  thrown  together  into  what  is  known  as 
the  internal  sphincter  muscle.  The  mucous  membrane 
is  gathered  together  in  folds  which  converge  at  the  ano- 
rectal  line,  ending  at  the  crypts  of  Morgagni.  These 


THE   RECTAL  VALVES.  23 

folds  are  known  as  the  columns  of  Morgagni.  With  the 
patient  in  the  knee-shoulder  position  and  the  rectum  in- 
flated, the  circumference  of  the  organ  when  dilated  will 
vary  from  live  to  eight  inches.  With  the  rectum  in- 
flated certain  definite  crescentic  folds  will  be  seen  stand- 
ing out  from  the  rectal  wall,  encircling  it  for  from  one- 
third  to  two-thirds  of  its  circumference.  They  appear 
at  definite  points  and  are  usually  three  in  number.  One 
extremity  appears  attached  lower  to  the  rectal  wall  than 


Fig.  3. 

Proctoscopic   View  of  the  Rectal  Valves. 

Semi-diagramatic. 

the  other,  and  they  are  arranged  in  such  a  manner  that 
on  proctoscopic  view  they  give  the  effect  of  three  project- 
ing ledges  arranged  in  the  form  of  a  spiral;  the  second 
being  attached  an  inch  to  an  inch  and  a  half  above  the 
middle  of  the  first;  and  the  third  at  a  point  about  the 
same  distance  above  the  middle  of  the  second.  The  first 
rectal  valve,  or  fold  of  Houston,  as  they  are  called,  is  sit- 
uated more  often  on  the  left  lateral  wall  of  the  rectum 
opposite  the  location  of  the  prostate  gland,  while  the 
third  is  at  or  below  the  recto-sigmoidal  juncture.  These 


24  LEVATOR  AN  I  MUSCLE. 

valves  are  not  simple  folds  of  mucous  membrane,  but 
contain  muscular  fibres  and  blood  vessels  and  present  all 
the  characteristics  of  a  typical  anatomical  valve.  They 
are  of  considerable  interest  and  importance  because  of 
the  fact  that  when  they  are  infiltrated,  thickened  or  en- 
larged, they  offer  more  or  less  obstruction  to  the  pas- 
sage of  the  fecal  current,  prevent  the  introduction  of  the 
rectal  tube,  and  interfere  with  the  administration  of 
enemata. 

Levator  Ani  Muscle.  Outside  of  the  External  sphinc- 
ter muscle,  this  is  the  most  important  muscle  with  which 
we  have  to  deal.  With  the  external  sphincter,  this  mus- 
cle practically  controls  the  act  of  defecation.  During 
defecation  the  levator  ani  and  external  sphincter  muscles 
are  relaxed,  and  the  feces  are  extruded  by  the  involun- 
tary action  of  the  muscular  coats  of  the  bowel,  assisted  by 
the  compression  and  contraction  of  the  abdominal  mus- 
cles under  the  control  of  the  will.  The  internal  sphinc- 
ter, in  all  probability  does  not  act  as  a  sphincter  at  all, 
but  co-operates  in  the  peristaltic  movement  of  the  in- 
ternal muscular  coat  of  the  intestine.  When  the  fecal 
mass  is  extruded,  the  anterior  portion  of  the  upper  por- 
tion of  the  anal  canal  is  fixed  by  the  recto-urethralis  mus- 
cle, which  is  a  definite  muscular  band  by  which  the  an- 
terior surface  of  the  bowel  at  the  juncture  of  the  rectum 
and  anus  is  connected  with  the  urethra.  The  pubo-rec- 
talis  portion  of  the  levator  ani  then  compresses  the 
sides  and  draws  the  posterior  portion  of  the  opening 
toward  the  pubis.  The  external  sphincter  then  completes 
the  evacuation  and  closes  the  anal  canal. 


25 


f.H. 


S.E. 


L.A. 


Fig.  4. 
Muscles  and  Nerves  of  the   Male   Pelvic  Outlet. 

T.  P.  Transversus  perinei   muscle. 

S.  E.  External    sphincter    muscle. 

L.  A.  Levator    ani    muscle. 

G.  M.  Glutens    maximus    muscle. 

C.  Coccyx. 

1.  H.  Inferior  hemorrhoidal   nerve. 

A.  Anus. 

P.  P.       Posterior    superficial    perineal    nerve. 
C.  T.       Central    tendinous    point   of    perineum. 

B.  C.       Bulbo-cavernousus    muscle. 

—The   Rectum;    Its   Diseases   and    Developmental   Defects, 
BV    Sir   Charles   Ball. 


26  LEVATOR  ANI  MUSCLE. 

The  levator  ani,  as  described  by  Thompson  and  Ball, 
is  composed  of  three  main  portions,  the  ilio-coccygeus, 
pubo-coccygeus  and  pubo-rectalis. 

"Ilio-Coccygeus  although  definitely  attached  to  the 
ilium  in  many  lower  animals,  in  man  takes  origin  from 
the  spine  of  the  ischium  and  from  a  portion  of  the  ob- 
turator fascia,  roughly  indicated  by  a  white  line  which 
extends  in  a  curve  from  the  spine  of  the  ischium  to  the 
back  of  the  pubis.  Although  in  older  text-books  this 
white  line  is  described  as  a  tendinous  origin  of  the  leva- 
tor  ani,  recent  observations  tend  to  show  that  but  few, 
if  any,  of  the  muscular  fibres  are  actually  attached  to 
it,  and  that  it  is  merely  a  thickening  of  the  pelvic  fascia. 
From  this  origin  the  ilio-coccygeus  extends  in  a  fan 
shape  to  be  inserted  into  the  side  of  the  sacrum  and  coc- 
cyx; it  is  thin  and  in  part  membranous,  and  must  be  re- 
garded as  a  degenerated  muscle  whose  primary  function 
in  connection  with  the  tail  is  lost,  but  in  virtue  of  its 
position  it  contributes  to  the  formation  of  the  pelvic  floor. 
It  has  no  direct  relation  to  the  rectum. 

"Pubo-Coccygeus  arises  from  the  back  of  the  pubis,  and 
also  from  the  obturator  fascia,  where  usually  its  fibres 
blend  with  those  of  the  ilio-coccygeus;  from  this  origin 
the  fibres  pass  almost  horizontally  back,  overlapping 
the  ilio-coccygeus,  closely  related  to  the  rectum  (and  va- 
gina), to  be  attached  to  the  coccyx  and  ano-coccygeal  liga- 
ment. A  few  of  the  anterior  fibres  descend  in  front  of 
the  rectum  to  the  perineal  body,  while  lateral  fibres  are 
continued  down  into  the  aponeurotic  sheath  which  sur- 
rounds the  anal  canal,  in  which  the  longitudinal  fibres  of 
the  external  coat  of  the  rectum  terminate. 

"Pubo-Rectalis,  or  sphincter  recti,  is  the  name  given 


LIGAMENTS  OF  THE  RECTUM.  27 

by  Holl  to  an  important  band  of  fibres  of  the  pubo-coccy- 
geus,  which  instead  of  being  inserted  into  the  coccyx  and 
its  ligamentous  connections,  is  continuous  with  the  fibres 
of  the  same  muscle  on  the  other  side,  forming  a  strong- 
muscular  cord  round  the  lateral  and  posterior  aspects 
of  the  upper  opening  of  the  anal  canal.  The  fibres  of 
the  pubo-rectalis  muscle  arise  from  the  back  of  the  pubis 
on  either  side,  under  cover  of  the  pubo-coccygeus,  and 
pass  between  the  layers  of  this  muscle,  with  more  or  less 
interchange  of  fibres,  to  the  back  of  the  rectum,  where 
they  are  continuous  with  the  fibres  of  the  same  muscle 
on  the  other  side.  It  is  the  most  muscular  portion  of  the 
levator  ani,  and  when  removed  from  a  formalin-hardened 
body  leaves  a  deep  groove  posteriorly  where  the  rectum 
turns  abruptly  into  the  anal  canal.  According  to 
Thompson,  although  traces  of  this  muscle  are  found  in 
some  lower  animals,  it  is  only  in  the  anthropoids  that 
we  find  a  muscular  sling  strongly  developed  for  the  first 
time,  which  in  man  has  become  evolved  into  such  an  imj 
portant  structure. ' ' 

Ligaments.  The  chief  ligaments  that  assist  in  sup- 
porting the  rectum  are  the  ano-coccygeal  and  lateral  lig- 
aments. The  ano-coccygeal  is  a  cord-like  ligament  which 
extends  from  the  tip  of  the  coccyx  to  a  point  near  the 
juncture  of  the  anus  and  rectum  on  its  posterior  sur- 
face. Attached  to  it  are  some  of  the  more  superficial 
fibres  of  the  external  sphincter.  Upon  either  side  of 
the  rectum,  just  beneath  the  lateral  reflections  of  the  peri- 
toneum are  connective  tissue  attachments  known  as  the 
lateral  ligaments  of  the  rectum.  It  is  important  to  re- 
member that  they  contain  the  middle  hemorrhoidal  ves- 
sels. 


28  RELATIONS  OF  THE  RECTUM. 

Relations  of  the  Rectum.  The  upper  half  of  the  rec- 
tum is  almost  entirely  surrounded  by  peritoneum.  In 
front  the  peritoneum  dips  down  between  the  rectum  and 
bladder,  forming  what  is  known  in  the  male  as  the  recto- 
vesical  pouch,  in  the  female  the  uterus  and  vagina  take 
the  place  of  the  bladder  and  the  pouch  is  known  here  as 
Douglas'  pouch.  The  distance  between  the  arue  and  the 
deepest  point  of  dipping  of  this  pouch  is  of  great  import- 
ance in  the  surgery  of  this  region,  and  the  distance  va- 
ries according  to  the  measurements  of  different  authors. 
The  average  distance  is  given  as  four  inches.  Cripps, 
after  careful  measurements  of  a  large  number  of  cada- 
vers, gives  the  distance  as  21/*?  inches  when  the  bladder 
and  rectum  are  emptied,  and  3^  inches  when  both  are 
distended.  From  this  lowest  point  on  the  anterior  sur- 
face of  the  rectum,  the  peritoneum  gradually  invests 
more  and  more  of  the  rectum  until  its  upper  portion  at 
the  posterior  wall  of  the  rectum  is  about  I1/?  inches  higher 
than  the  anterior.  Where  the  two  folds  of  peritoneum 
come  together  behind  the  rectum,  it  forms  a  complete 
mesentery  which  is  continuous  with  that  of  the  sigmoid. 

Other  relations  of  the  rectum  are  in  front  with  the 
bladder,  seminal  vesicles,  vas  deferens,  urethra,  prostate 
in  the  male  and  the  vagina,  uterus  and  adnexa  in  the 
female.  Posteriorly  it  lies  against  the  hollow  of  the 
sacrum  and  the  coccyx.  Laterally  its  upper  portion  is 
oftentimes  in  close  contact  with  coils  of  the  small  intes- 
tine when  they  descend  into  the  pelvis.  On  either  side 
of  the  lower  half  of  the  rectum  are  located  the  ischio 
rectal  fossae. 

Ischio-Rectal  Fossa.  The  ischio-rectal  space  or  fossa 
is  a  triangular  space  filled  with  loosely  organized  con- 


ISCHIO-RECTAL  FOSSAE SIGMOID  COLON.  29 

nective  tissue  and  fat,  situated  on  either  side  of  the  rec- 
tum between  it  and  the  tuberosity  of  the  ischium.  The 
apex  of  the  cavity  is  directed  upward  and  the  base 
towards  the  perineum. 

Gant  describes  these  fossae  as  follows:  " Their  depth 
varies  from  one  and  a  half  inches  in  front  to  two  inches 
behind,  and  at  their  lowermost  and  broadest  part  they  are 
a  little  more  than  an  inch  in  width.  Internally  these 
spaces  are  in  relation  to  the  external  and  internal 
sphincters,  coccygeus,  and  levator  ani  muscles;  exter- 
nally with  the  tuber  ischii  and  obturator  fascia;  ante- 
riorly with  superficial  and  perineal  fascias;  and  poste- 
riorly with  the  border  of  the  gluteus  maximus  muscles, 
the  investing  fascia  of  which  is  continuous  with  the  great 
sacro-sciatic  ligament.  Within  a  sheath  formed  by  the 
obturator  fascia  are  to  be  found  the  internal  pudic  artery, 
veins,  and  nerves.  The  inferior  hemorrhoidal  vessels  and 
nerves  pass  through  the  central  portion  of  the  ischio-rec- 
tal  fossae  on  their  way  to  the  anal  canal  to  which  they 
are  distributed,  while  in  the  anterior  portion  of  these 
spaces  are  the  superficial  perineal  vessels  and  nerves. 
The  fat  and  connective  tissue  filling  these  spaces  act  as 
elastic  supports  for  the  rectum  and  are  largely  responsi- 
ble for  the  lateral  walls  of  the  rectum  remaining  in  con- 
tact. These  fossae  are  of  surgical  importance  because  of 
the  frequency  with  which  abscesses  and  fistulas  are  found 
in  this  locality." 

The  Sigmoid  Colon.  The  sigmoid  colon  is  that  por- 
tion of  the  large  intestine  extending  from  its  juncture 
with  the  rectum  at  the  left  sacro-iliac  symphysis  to  a  point 
opposite  the  crest  of  the  ileurn  where  it  becomes  continu- 
ous with  the  descending  colon.  It  derives  its  name  of 


30  BLOOD   SUPPLY. 

sigmoid  colon  or  flexure  from  its  double  curve.  It  is 
entirely  a  peritoneal  organ  and  is  attacliecTBy  a  mesen- 
tery which  is  known  as  the  meso-sigmoid.  Its  average 
length  is  from  18  to  20  inches.  When  empty  the  sigmoid 
colon  lies  in  the  left  iliac  fossa  and  a  portion  of  it  may 
dip  down  into  the  pelvis.  When  filled,  it  may  extend 
over  and  occupy  the  right  iliac  fossa  as  well  as  the  left. 
It  is  composed  of  four  coats  corresponding  to  those  of 
the  rectum  and  in  addition  has  on  its  outer  surface  di- 
rectly opposite  to  its  mesenteric  attachment  a  longitudi- 
nal muscular  band.  Its  narrowest  portion  is  at  its  junc- 
ture with  the  rectum.  On  account  of  the  length  of  its 
meso-colon,  the  sigmoid  is  of  importance  because  of  its 
tendency  in  some  cases  to  prolapse  or  become  invaginated 
into  the  rectum. 

Blood  Supply.  (See  frontispiece.)  The  arteries  of  the 
rectum  are  the  superior,  middle  and  inferior  hemorrhoid- 
al,  and  occasionally  a  branch  from  the  middle  sacral  and 
the  vesical.  The  largest  and  most  important  vessel  is  the 
superior  hemorrhoidal  which  is  a  direct  continuation  of 
the  inferior  mesenteric.  This  vessel,  which  is  situated  at 
the  posterior  portion  of  the  rectum,  slightly  to  the 
left  of  the  median  line,  passes  down  from  the  mesentery 
of  the  sigmoid  colon  to  the  upper  portion  of  the  rec 
turn  at  a  point  about  4  to  4a/2  inches  from  the  anus. 
It  here  divides  into  two  main  branches,  the  right  and 
left,  which  almost  immediately  subdivide  into  three  or 
four  smaller  branches,  which  run  down  the  rectum 
almost  to  the  anus,  connected  by  a  number  of  anasto- 
motic  branches,  some  of  which  pass  in  through  the 
muscular  coat  of  the  bowel  to  the  submucous  coat 
where  they  end  in  a  number  of  terminal  branches, 


LYMPHATICS.  31 

one  being  usually  found  in  each  of  the  columns  of 
Morgagni.  The  middle  hemorrhoidal  artery  arises 
from  the  internal  iliac  and  enters  the  rectum  on  either 
side  through  the  lateral  ligament,  where  it  breaks  up  into 
a  number  of  branches  which  supply  the  outer  coats  of 
the  bowel  but  not  the  mucous  membrane.  The  inferior  or 
external  hemorrhoidal  arises  from  the  internal  pudic  and 
passing  through  the  ischio-rectal  fossa,  is  distributed  to 
the  muscles  of  the  anal  canal.  This  artery  supplies  the 
cutaneous  portion  of  the  anus,  the  skin  surrounding  the 
margin  of  the  anus,  but  not  the  mucous  membrane. 

Venous  Supply.  The  veins  of  the  rectum  follow  the 
arteries.  The  superior  hemorrhoidal  vein  returns  the 
blood  from  the  rectum  into  the  inferior  mes enteric  vein 
and  directly  to  the  portal  circulation.  Like  the  rest  of 
the  portal  system,  the  superior  hemorrhoidal  vein  is  not 
supplied  with  valves.  The  middle  and  inferior  hemor- 
rhoidal veins  return  the  blood  from  the  anus  and  circum- 
anal  region  by  way  of  the  internal  iliac  into  the  general 
venous  circulation.  The  hemorrhoidal  plexus  is  com- 
posed of  a  large  number  of  anastomosing  veins  situated 
in  the  submucous  and  subcutaneous  tissues  of  the  anal 
canal,  and  is  emptied  largely  by  the  superior  hemor- 
rhoidal veins. 

Lymphatics.  The  lymphatic  vessels  from  the  mucous 
membrane  of  the  rectum  proper  communicate  with  a  num- 
ber of  small  glands  known  as  the  post-rectal  glands,  lying 
between  the  rectum  and  the  sacrum,  from  which  lympha- 
tic vessels  pass  up  into  the  mesentery  of  the  sigmoid. 
The  lymphatics  from  the  skin  of  the  anus  and  circum-anal 
region  communicate  by  the  inner  surface  of  the  thighs 
with  the  inguinal  glands.  An  important  point  to  remein- 


32  NERVE   SUPPLY. 

ber  in  this  connection  is  that  early  involvement  of  the 
inguinal  glands  would  indicate  disease  either  malignant 
or  infectious  situated  in  the  anal  region,  while  infectious 
or  malignant  diseases  of  the  rectum  proper  would  extend 
to  and  infiltrate  the  pre-sacral,  lumbar  and  mesenteric 

glands. 

The  Nerve  Supply.      The  rectum  is  not  supplied  with 
sensory  nerves,  particularly  in  its  upper  half.    The  anus 
and  anal  canal  and  lower  portion  of  the  rectum,  on  the 
contrary,  is  liberally  supplied.     This  accounts  for  the 
comparative  absence  of  pain  when  the  rectum  proper  is 
diseased,  and  the  intense  suffering  caused  by  any  lesion 
in  the  anal  canal.    The  sensory  nerves  of  the  anus  are 
derived  from  the  sacral  plexus.    The  external  sphincter 
muscle  receives  its  nerve  supply  by  branches  from  the 
sacral  plexus,  especially  the   third  and  fourth  nerves. 
The  lesser  sphincterian  nerve  of  Morestin  which  is  of 
*reat  importance  in  the  production  of  local  anesthesia 
for  the  dilatation  of  the  external  sphincter,  is  described 
by  Tuttle  as:  ''A  filament  coming  off  from  the  5th  and 
6th  sacral  nerves  which  passes  down  the  hollow  of  the 
sacrum  through  the  levator  ani  muscle  and  the  recto- 
coccygeus  ligament,  finally  reaching  the  posterior  super- 
ficial surface  of  the  external   sphincter  muscle."     The 
levator  ani  is  also  supplied  by  branches  from  the  sacral 
plexus.    .While  the  anus  and  rectum  both  receive  their 
nerve  supply  from  the  sympathetic  and  cerebro-spinal 
systems,  the  principal  nerve  supply  of  the  rectum  proper 
is  sympathetic,  it  receiving  branches  from  the  mesenteric, 
sacral  and  hypo  gastric    plexuses.      From    the    cerebro- 
spinal  system  it  is  supplied  by  some  filaments  from  the 
third,  fourth  and  fifth  sacral  nerves. 


CHAPTER  II 

SYMPTOMS  WHICH  SHOULD  CALL  ATTENTION 
TO  THE  RECTUM. 

It  has  been  estimated  that  one  patient  out  of  every 
seven  is  suffering  from  some  disease,  the  relief  of  which 
would  be  assisted,  or  entirely  accomplished,  by  the  treat- 
ment of  pathological  conditions  discovered  only  upon 
rectal  examination.  Many  patients  consult  a  physician 
whose  localized  pain,  tenderness,  irritation,  or  other 
symptoms,  call  attention  at  once  to  the  ano-rectal  region. 
Many  other  symptoms,  however,  of  a  more  general  char- 
acter, such  as  disturbances  of  digestion,  menstruation, 
and  the  functions  of  the  urinary  organs,  as  well  as  head- 
ache, backache,  sciatica,  anemia,  and  sometimes  even 
asthma  and  acne  vulgaris,  are  more  remote  evidences  of 
diseases  originating  within  the  confines  of  the  lower 
bowel. 

Pain  is  the  most  frequent  symptom  which  causes  a 
patient  to  seek  a  physician's  aid.  It  may  be  located  at 
the  anal  orifice,  in  the  anal  canal  or  the  lower  two  inches 
of  the  rectum.  It  may  be  sharp,  coming  on  suddenly, 
paroxysmal,  burning,  throbbing,  or  of  a  dull  aching  char- 
acter. The  character  of  the  pain  and  the  time  of  its  onset 
with  relation  to  the  bowel  movement,  is  important,  as  it, 

33 


34  PAIN TETsl  DERNESS SPASM BLEEDING. 

of  itself,  is  often  a  clue  to  the  diagnosis.  Sharp,  acute 
pain,  of  a  cutting,  burning  or  stinging  quality,  coming  on 
with  the  stool  or  following  it,  almost  invariably  points  to 
some  lesion  in  the  anal  canal.  Sudden,  darting  pains,  oc- 
curing  in  the  intervals  between  stools,  also  point  to  the 
same  region  for  their  origin.  Pain  of  a  throbbing  char- 
acter indicates  acute,  or  sub-acute  inflammatory  condi- 
tions. These  may  be  either  integumentary,  peri-anal,  or 
peri-rectal  abscesses.  In  these  latter  conditions,  a  rise 
in  temperature  will  be  noted,  and  the  blood  count  will 
show  a  leucocytosis.  Pain  of  a  dull  aching  character, 
whether  intermittent  or  constant,  may  be  caused  by 
hemorrhoids,  prolapse,  polypus,  fistula,  ulceration  of  the 
rectum,  benign  growths  such  as  rectal  adenoids,  or  ma- 
lignant disease. 

Many  diseased  conditions  of  the  rectal  cavity  may 
progress  to  an  astonishing  degree  without  causing  any 
local  pain  on  account  of  the  lack  of  sensory  innervation 
of  this  region.  Pain,  however,  referred  to  other  por- 
tions of  the  body,  such  as  the  sacrum,  uterus,  vagina, 
bladder,  urethra,  penis,  scrotum,  or  down  the  sciatic 
nerves,  or  up  into  the  inguinal  region,  is  frequently 
caused  by  pathological  conditions  in  the  rectum,  which 
cause  no  local  pain  whatever. 

Tenderness  in  the  circum-anal  region,  usually  points 
to  abscess  formation,  or  fistula.  Tenderness  of  the  anus 
indicates  inflammatory  conditions  or  ulceration. 

Spasm  is  caused  by  anything  which  irritates  the 
sphincter  muscles,  Anal  fissure,  ulcer  or  abscess,  as  well 
as  hypertrophied  papillae,  or  foreign  bodies,  are  the  usual 
causes  of  anal  spasm. 

Bleeding  is  one  of  the  most  frequent  symptoms  ac- 


BLEEDING  FROM  THE  EECTUM.  35 

companying  diseases  of  the  anus  and  rectum,  and  it  is 
one  of  the  symptoms  above  all  others  which  should  call 
for  complete  examination  of  the  anus,  rectum  and  sig- 
moid.  Bleeding  is  more  common  in  adults  than  in  chil- 
dren. It  may  be  very  profuse,  or  slight,  as  simply  a  drop 
or  two.  It  usually  occurs  during  defecation,  but  may 
occur  during  the  intervals  as  well.  The  blood  may  be 
discharged  either  liquid  or  clotted.  It  may  be  pure,  or 
mixed  with  mucus,  pus,  feces,  or  other  debris.  Fresh 
blood  discharged  from  the  anus,  is  usually  from  a  local 
hemorrhage,  but  may  have  descended  from  the  sigmoid 
or  colon.  The  darker  in  color  the  blood,  the  higher  in  the 
bowel  its  source.  .Rectal  hemorrhage  may  be  caused: 

(1)  By  local  disease;  (2)  by  traumatism;  or  (3)  following 
operation.    The  cause  of  the  last  is  so  evident  that  it  will 
not  be  considered  and  trauma  will  simply  be  mentioned. 
The  local  diseases  of  the  rectum  which  may  cause  hemor- 
rhage   are:    (1)    Internal    hemorrhoids.    (2)    Prolapse. 

(3)  Fissure.    (4)  Ulceration.     (5)  Stricture.     (6)  Malig- 
nant   disease.      (7)    Proctitis.      (8)    Fecal    impaction. 
(9)  Polypus.     (10)   Villous  growths.     (11)   Chancroids 
and  chancres.     (12)  Condylomata.    Other  diseases  caus- 
ing local  rectal  hemorrhage  are:  (1)  Amoebic  dysentery. 

(2)  Intussusseption.  (3)  Embolism  of  mesenteric  artery. 

(4)  Congestion  of  the  portal  vein. 

The  general  systemic  diseases  such  as  Malaria,  Scurvy, 
Tuberculosis,  Typhoid  Fever,  and  others,  which  may 
during  their  course  give  rise  to  bloody  stools,  are  not 
considered  in  this  work  because  the  diseased  condition  is 
very  evident  long  before  the  hemorrhage  presents  itself 
It  may  be  mentioned,  however,  that  the  passage  of  some 
mucus  streaked  with  blood  in  typhoid  fever  is  often  a 


36  ITCHING. 

warning  signal  of  impending  hemorrhage,  and  perfora- 
tion. 

The  type  of  hemorrhage  characteristic  of  the  various 
conditions  will  be  taken  up  as  each  variety  is  discussed  in 
its  respective  chapter.  The  author  has  seen  so  many 
cases  of  Cancer  of  the  rectum,  which  had  gone  on  to 
almost  complete  occlusion  of  the  rectum  and  involve- 
ment of  other  organs ;  whose  lives  might  have  been  saved 
if  proper  and  complete  examination  of  the  rectum  had 
been  made  when  hemorrhage  first  manifested  itself,  that 
he  is  constrained  to  lay  great  stress  on  the  importance 
of  this  symptom.  Rectal  hemorrhage,  no  matter  Iwiv 
slight,  should  never  be  taken  for  granted  as  diagnostic  of 
hemorrhoids  or  any  other  disease,  but  should  call  for  a 
complete  examination,  the  technique  of  which  will  be 
explained  in  the  following  chapter. 

Itching  of  .the  anus  or  of  the  perineum,  scrotum,  x>r 
vulva,  is  a  frequent  accompanying  symptom  of  many  anal 
and  rectal  diseases.  In  fact  it  may  occur  with  any  of 
them.  The  degree  and  severity  of  the  itching  varies  from 
a  slight  feeling  of  uneasiness  and  irritation,  a  mild  prick- 
ing sensation  following  stools,  to  the  most  intense,  per- 
sistent, aggravating  condition  characteristic  of  the  more 
severe  types  of  pruritus  ani.  Many  constitutional  dis- 
eases, such  as  Diabetes,  and  Uric  acidosis  predispose 
the  patient  to  itching  of  any  part  of  the  body.  When 
such  a  patient  has  a  diseased  condition  of  any  part  of 
the  ano-rectal  region,  however  slight,  he  usually  develops 
pruritus  ani  in  addition  to  his  other  symptoms.  In  the 
author's  experience,  almost  every  case  showing  itching 
as  the  predominating  symptom  has  been  demonstrated  to 


PROTRUSIONS ELEVATIONS.  37 

have  had  its  origin  in  some  local  diseased  condition  of 
the  ano-rectal  region. 

Protrusions.  While  the  most  common  protrusion  of 
which  the  patient  complains  is  some  variety  of  hemor- 
rhoids ;  it  should  be  born  in  mind  that  there  are  several 
other  conditions  made  manifest  by  protrusion  at  the  anal 
orifice,  among  which  may  be  mentioned :  Prolapsus,  Poly- 
pi, Hypertrophied  Papillae,  and  Cancer.  In  questioning 
a  patient  regarding  a  protrusion,  one  should  find  out 
whether  they  appear  with  stools  or  not ;  and  whether  or 
necessary  to  produce  it,  or  whether  it  appears  sponta- 
neously; whether  it  can  be  replaced,  and  if  so,  whether 
easily  or  not.  One  should  inquire  as  to  their  number, 
whether  they  appear  with  stools  or  not ;  and  whether  or 
not  their  appearance  or  replacement  is  accompanied  by 
pain. 

Elevations  found  in  the  peri-anal  region  may  be 
smooth  and  rounded ;  rough,  hard,  or  soft  and  fluctuating ; 
and  are  caused  by  external  hemorrhoids,  abscesses,  lipo- 
mata,  condylomata,  or  the  external  openings  of  fistulae. 
A  rounded  elevation  occurring  at  one  side  of  the  anus, 
accompanied  by  pain  of  a  throbbing  character  with  some 
rise  of  temperature,  will  be  found  due  to  a  marginal  or 
ischio-rectal  abscess.  A  hard,  rounded  protruberance, 
occuring  suddenly  at  the  anal  margin,  accompanied  by 
intense  throbbing  pain,  will  be  found  to  be  an  acute 
thrombotic  external  hemorrhoid.  A  cluster  of  small, 
rough  elevations  at  the  anal  opening,  usually  posterior, 
is  the  most  common  manifestation  of  condylomata. 

A  small  papular  elevation  anywhere  in  the  peri-anal 
region  from  which  a  purulent  discharge  exudes,  is  al- 
most invariably  the  external  opening  of  a  fistula. 


38  DISCHARGE CONSTIPATION DIARRHOEA. 

Discharge.  A  history  of  discharge  from  the  anus 
should  always  suggest  a  proctoscopic  examination. 
Hemorrhage  has  already  been  described  above.  While 
mucus  may  be  caused  by  any  irritation,  acute  or  chronic, 
and  accompanies  practically  all  forms  of  rectal  disease; 
it  may  originate  in  some  inflammatory  condition  of  the 
colon.  The  sigmoid  should  therefore  always  be  explored 
when  a  mucous  discharge  is  met  with.  Purulent  dis- 
charge may  come  from  colitis,  but  more  often  points  to 
abscess,  blind  internal  fistula,  rectal  ulceration,  or  malig- 
nant disease.  The  odor  which  accompanies  the  dis- 
charge caused  by  the  last  mentioned  condition,  is  almost 
diagnostic  in  itself.  Many  patients  who  complain  of  pru- 
ritus, or  local  irritation  of  the  anal  region,  will  also  com- 
plain of  the  moisture  of  the  parts.  It  is  well  to  bear  in 
mind  the  possibility  of  disease  of  the  Morgagnian  crypts 
as  the  origin. of  this  symptom. 

Constipation.  No  case  of  constipation,  particularly 
of  the  chronic  variety,  should  ever  be  treated  until  a 
complete  examination  has  been  made.  So  many  cases  of 
so-called  constipation,  which  is  purely  a  functional  con- 
dition, are  in  reality  due  to  mechanical  causes.  Ente- 
roptosis,  floating  kidney,  prolapse,  stricture,  hypertro- 
phied  rectal  valves,  enlarged  prostate,  uterine  displace- 
ments, adhesions,  rectocele,  perineal  lacerations,  fecal 
impaction,  and  many  other  diseased  conditions,  often  act 
in  a  purely  mechanical  way,  causing  obstipation,  which 
can  only  be  discovered  after  proper  examination. 

Diarrhoea.  Chronic  diarrhoea  per  se,  or  alternating 
with  constipation,  so  frequently  occurs  as  a  symptom 
of  carcinoma  and  ulceration,  that  these  diseases  should  be 
excluded  by  examination  before  treatment  is  commenced. 


ALTEKED  STOOLS SACRAL  BACKACHE SHOOTING  PAINS.  39 

Persistent  diarrhoea,  unaccompanied  by  pain,  occurring 
in  an  apparently  healthy  individual,  is  very  suggestive  of 
beginning  malignant  disease. 

Altered  Stools.  Deviations  in  the  normal  appear- 
ance of  the  stools  are  often  very  suggestive.  The  large, 
hard  stool  of  prolonged  fecal  retention,  giving  a  vastly 
different  meaning  than  the  narrow  tape-like  or  pipe-stem 
stool  of  stricture.  The  color,  consistency  and  amount  of 
the  stool,  as  well  as  the  appearance  of  blood,  pus,  or 
mucus  with  the  movement,  as  has  been  noted  above,  are 
all  of  importance. 

Sacral  backache  is  often  the  only  subjective  symptom 
of  beginning  malignant  disease.  It  often  accompanies  in- 
ternal hemorrhoids,  prolapse,  impaction,  and  various 
benign  growths.  It  is  a  symptom  which  should  always 
call  for  rectal  examination.  Many  obstructive  conditions 
of  the  sigmoid,  as  well  as  sigmoiditis,  and  fecal  impac- 
tion, will  often  cause  a  sense  of  weight  or  constriction  in 
the  pelvis.  When  this  occurs  in  females,  and  disease  of 
the  uterus  or  adnexa  are  excluded  by  gynecological  exam- 
ination, the  sigmoidoscope  should  be  used. 

Shooting  pains  down  the  limbs,  particularly  the  left, 
may  accompany  all  forms  of  rectal  disease.  Sciatica  has 
been  so  perfectly  simulated  by  rectal  ulcer  that  diagnos- 
ticians have  repeatedly  been  led  astray.  This  is  often 
the  predominating  symptom  in  lateral  ulcer  of  the  rec- 
tum. Ischio-rectal  abscess,  particularly  of  the  left  fossa, 
frequently  causes  pains  shooting  down  the  limbs. 

Crampy,  painful,  and  scanty  menstruation  occur- 
ring in  women  who  have  perfectly  normal  genital  organs 
will  be  found  upon  rectal  examination  to  be  due  in  many 


40  PAINFUL  URINATION ANEMIA FOREIGN  BODY. 

cases  to  ulceration  of  the  anterior  rectal  wall,  fissure,  or 
hemorrhoids. 

Frequent  and  painful  urination,  pressure  symptoms 
in  the  bladder,  pain  and  burning  at  the  vesical  neck, 
enuresis :  all  may  be  due  to  a  number  of  anal  and  rectal 
diseased  conditions.  Fissure  and  ulcer  are  the  most 
frequent  causes  of  .bladder  irritability. 

Loss  of  appetite,  impaired  digestion,  nausea,  headache, 
sallow  complexion,  and  fever  are  frequently  some  of  the 
symptoms  of  an  auto-intoxication  caused  by  some  inter- 
ference with  the  functions  of  the  lower  bowel,  whose  cause 
will  be  found  upon  rectal  examination. 

Anemia.  Persons  suffering  from  anemia  should  al- 
ways be  questioned  as  to  the  existence  of  rectal  hemor- 
rhage as  not  infrequently  the  loss  of  blood  from  internal 
hemorrhoids,  or  ulceration  is  so  extensive  as  to  account 
for  the  anemic  condition. 

Restlessness  in  Children.  When  children  are  restless 
at  night  and  are  continually  picking  at  the  nose  or 
scratching  the  anus  or  genitals,  an  examination  of  the 
rectum  will  often  disclose  the  presence  of  pin  worms. 

Foreign  Body.  The  history  of  the  swallowing  of  a 
foreign  body  such  as  a  pin  or  a  fish  bone,  followed  in  a 
few  days  by  anal  pain  or  tenesmus,  should  call  for  a 
rectal  examination,  and  the  offending  cause  of  the  trou- 
ble will  be  found  not  infrequently  protruding  from  the 
mouth  of  one  of  the  Morgagnian  crypts. 


CHAPTER  III 


EXAMINATION  OF  THE  PATIENT. 

The  first  and  most  important, consideration  is  the  loca- 
tion and  arrangement  of  the  examining  room.  The  ideal 
suite  of  offices  should  include  besides  a  reception  room,  a 
consultation  room,  an  examining  or  operating  room,  and 
a  resting  or  recovery  room.  These  two  latter  rooms 
should  be  situated  at  some  distance  from  the  reception 
room  and  should  be  separated  from  the  other  rooms  by 
walls  which  are  sound  proof.  It  is  not  a  pleasant  pros- 
pect for  a  patient  in  the  reception  room  nervously  await- 
ing his  or  her  turn,  to  overhear  through  flimsy  plaster  or 
glass  partitions,  the  recital  of  another's  ailments,  or  the 
weeping  of  a  hysterical  patient  on  the  operating  table. 
TVhere  a  glass  partition  is  all  that  separates  the  operating 
room  from  the  reception  room,  those  in  waiting  are  often 
treated  to  a  shadowgraphic  representation  of  the  per- 
formance going  on  within. 

One  who  expects  to  do  minor  surgery  or  treatment 
work  should  equip  himself  properly  for  the  same.  A 
properly  fitted-out  and  furnished  operating  room  should 
be  provided,  which  could  also  serve  as  an  examining 
room  as  well.  The  room  should  be  large  enough  so  as 
not  to  be  uncomfortably  crowded  with  the  furniture  and 

41 


42  EXAMINING  BOOM. 

paraphernalia  necessary,  and  yet  small  enough  to  be  com- 
pact. The  floor  should  be  of  tile  or  granolithic  material 
so  as  to  be  water  tight  and  easily  cleansed.  The  walls 
should  be  tiled,  enameled,  or  treated  with  some  material 
that  will  stand  scrubbing.  All  corners  should  be  rounded 
off  and  as  little  woodwork  as  possible  should  enter  into 
its  construction. 

The  location  of  the  suite  will  depend  largely  upon  the 
location  of  the  building  itself,  but  where  there  is  a  choice, 
it  will  depend  upon  whether  the  strongest  light  is  desired 
in  the  forenoon  or  afternoon.  Heavy  shades  should  be 
provided  so  that  the  room  may  be  darkened  when  arti- 
ficial light  is  to  be  used.  The  walls  and  everything  in 
the  room,  as  far  as  possible,  should  be  white.  White  al- 
ways gives  the  patient  an  impression  of  cleanliness  at 
once;  and  the  slightest  soiling  is  so  conspicuous  that 
they  must  be  kept  clean. 

The  furniture  necessary  consists  of  a  surgical  table, 
or  chair,  which  can  be  adjusted  to  various  positions ;  an 
aseptic  glass  and  metal  instrument  case,  glass  top  instru- 
ment table,  revolving  stool,  sterilizer  stand,  foot  tub ; 
with  enameled  bowls  and  dressing  basins,  pail,  com- 
pressed air  tank,  and  plumbing,  electric  light  wiring,  and 
other  fixtures  according  to  the  ideas  of  the  individual. 

If  it  is  not  possible  to  have  a  toilet  room  adjoining  the 
operating  room,  a  commode  should  be  added  to  the 
equipment.  A  retiring  or  recovery  room  is  almost  a 
necessity  as  well. 

The  author  prefers  an  examining  table  to  a  surgical 
chair.  He  believes  that  it  is  not  more  distasteful  to  the 
patient  to  get  up  on  a  table  to  be  examined,  than  it  is  to 
be  seated  in  a  chair  and  by  the  turn  of  a  crank,  to  be 


EXAMINING    TABLE. 


43 


Fig.  5. 
Columbus  Operating  Table. 

This  is  a  light  but  strong  all  metal  operating  table,  particularly 
adapted  for  office  work.  It  may  be  thrown  into  any  position  that  either 
surgical  chair  or  table  can  be. 

jerked  or  jarred,  or  flopped  into  position.  Surgical 
chairs  are  cumbersome  and  always  getting  out  of  order, 
and  are  not  to  be  compared  with  a  nice,  clean  operating 
table  of  white  enameled  iron  which  can  be  adjusted  to  any 


44 


OFFICE    EQUIPMENT. 


position  required.  Hair-stuffed  cushions  covered  with 
white  rubber  and  not  exceeding  one  inch  in  thickness  are 
placed  on  top  of  the  table.  The  cushions  should  be  thick 
enough  so  as  to  counteract  the  hardness  of  the  table,  and 
yet  not  so  thick  that  the  patient's  buttocks  sink  down 
into  them. 


Fig.  6. 
A  Simple  Form  of  Instrument  Sterilizer  for  Office  Use. 

Plenty  of  clean  white  sheets  should  be  always  on  hand 
and  the  examiner  will  find  it  more  comfortable  and  clean- 
ly to  wear  a  white  cotton  coat  such  as  are  commonly  worn 


Fig.  7. 
A  Small  Instrument  and  Dressing  Sterilizer. 

This  is  a  very  simple  and  popular  form  of  steam  sterilizer.  The  dres- 
sings for  an  office  operation  may  be  sterilized  in  the  trays  above  the  boil- 
ing instruments. 


OFFICE   EQUIPMENT. 


45 


by  dentists.  The  author  has  found  the  electric  head  light 
very  useful  where  the  interior  of  the  rectum  is  to  be 
examined,  and  believes  it  so  far  superior  to  the  head 
mirror  and  lamp  that  he  no  longer  uses  the  latter. 

"While  it  is  extremely  desirable  to  have  such  an  equip- 
ment, as  has  been  described  above,  a  very  satisfactory 
examination  can  be  made  on  any  sort  of  a  table  or  bed 


Fig.  8. 

Characteristic   Sitting   Posture  Assumed  by  Patients   Suffering  from 
Ano-Rectal    Disease. 


46 


OBTAINING  HISTORY  OF  RECTAL  CASE. 


with  the  aid  of  a  good  light.  The  technique  which  the 
author  uses  will  be  described,  not  because  it  will  be  found 
the  best  by  all  practitioners,  but  because  he  has  found  it 
the  best  and  most  satisfactory  in  his  experience. 

The  patient  should  first  be  asked  into  the  consulting 
room,  and  in  order  to  put  him  at  his  ease,  he  should 
be  allowed  to  tell  the  story  of  his  ailments  in  his  own 
way.  As  he  mentions  symptoms  or  salient  points  which 
are  pertinent,  they  should  be  noted  down  for  use  in 


Fig.  9. 
The   Quadrants  of  the  Anus. 

1.  Right  anterio-lateral  quadrant. 

2.  Left  anterio-lateral  quadrant. 

3.  Right  posterio-lateral  quadrant. 

4.  Left  posterio-lateral  quadrant. 


PREPARATION    FOR    EXAMINATION.  47 

questioning  him  later.  When  he  has  finished,  he  should 
be  questioned  in  a  more  systematic  manner,  and  his  his- 
tory noted  on  a  special  blank  or  card  kept  for  the  pur- 


HIBTONY     Or     CASC     No 


Fig.  10. 

A  Simple  Form  of  Record  Card  Used  by  the  Author. 
Actual   size,   four  by   six   inches. 

pose.  The  various  symptoms  brought  out  in  this  way, 
will  often  suggest  a  tentative  diagnosis,  but  as  has  been 
stated  in  the  preceding  chapter,  nothing  should  be  taken 
for  granted  and  a  complete  rectal  examination  insisted 
upon.  The  patient  is  then  taken  into  the  examining  room 
and  prepared  for  the  examination.  All  clothing,  corsets, 
tight  waist  bands,  or  anything  which  constricts,  or  has  a 
tendency  to  interfere  with  respiration,  or  to  crowd  the 
abdominal  organs,  or  intestines  out  of  place,  should  be 
loosened  or  removed.  The  patient  is  then  placed  on  the 


48 


DIGITAL  EXAMINATION. 


table  in  the  left  lateral  or  Sims'  position  and  covered 
with  sheets  in  such  a  manner  that  there  is  never  any  un- 
necessary exposure. 


In  Account  WIT 


DR.     LOUIS    J.     H'KSCHMAN 
DETROIT 

_ ADDRESS. 


»0«°I*Hie        1     2345-678    9  10  11  12  iVlY  15 

BEhDERED                                                                          CMAftGtS 
6  if  18  19  »  21  »  21  24  25  K  33  28  29  X  31 

DATE 

Fig.  11. 

Reverse  Side  of  the  Preceding  on  Which  the  Account  with  the 
Patient  Can  Be  Kept. 

Size,  four  by  six  inches. 

With  the  patient  so  placed  as  to  get  good  day  light,  or 
by  the  aid  of  the  head  light,  the  anus,  perineum,  buttocks, 
and  the  genital  organs  are  carefully  examined.  Discolor- 
ations,  protrusions,  elevations,  swellings,  abrasions, 
cracks,  skin  eruptions,  crusts,  scars,  discharge,  or  any 
other  abnormal  appearances  of  the  parts  should  be  care- 
fully noted. 

With  the  patient  in  the  same  position,  digital  examina- 
tion is  next  in  order.  It  is  well  to  have  in  readiness  a 
bowl  of  some  antiseptic  solution,  preferably  one  which 
will  not  attack  steel  instruments.  The  author  has  found 
a  1-10,000  solution  of  mercuric  iodide  the  most  satisfac- 


EXTERNAL   INSPECTION. 


Fig.  12. 

External    Inspection. 

This  drawing  well  illustrates  the  posture  of  both  examiner  and  patient, 
and  shows  the  extent  to  which  the  anus  may  be  dilated  by  traction  of  the 
skin  of  the  buttocks. 


Fig.  13. 

Electric    Magnifying    Headlight. 

This  is  a  very  simple,  inexpensive,  and  very  satisfactory  electric  head- 
light. It  may  be  used  either  on  the  street  current  or  dry  cell  battery.  It 
is  very  light,  compact,  and  can  be  so  adjusted  that  the  light  is  brought 
between  the  operator's  eyes.  There  is  a  condensing  lens  blown  onto  the 
front  of  the  lamp  greatly  increasing  its  efficiency. 


50  LUBRICANTS  FOR  DIGITAL  EXAMINATION. 

tory.     Its  germicidal  power  is  equal  to  that  of  the  bi- 
chloride in  the  strength  of  1-2,000. 

Finger  cots  should  always  be  at  hand.  The  examining 
finger  protected  by  the  finger  cot  should  always  be  well 
lubricated  before  an  examination  is  attempted.  There 
are  a  number  of  excellent  commercial  lubricants  on  the 
market,  such  as  Hartz's  "Lubra-Septol"  and  Van  Horn's 


Fig.  14. 

Method  of  Applying  Lubricant  From  Collapsible  Tube  to  Examining 
Finger  Protected  With  a  Rubber  Finger  Cot. 

"  K-Y,"  but  sterile  vaseline  or  oil  will  be  found  to  answer 
the  purpose  equally  as  well.  The  author  uses  a  lubri- 
cant which  has  given  him  perfect  satisfaction.  It  is  pre- 
pared as  follows: 

^     Oxy-cyanide  of  Mercury 0.246 

Glycerine 20. 

Tragacanth 3. 

Water 100. 

Dispense  in  two  ounce  collapsible  lead  tubes. 


POSTURES  FOE  DIGITAL  EXAMINATION. 


51 


The  posture  of  the  patient  for  digital  examination  is 
very  important.  The  old  method  of  having  a  patient 
simply  bend  or  lean  over  a  chair  or  table,  then  inserting 
the  index  finger,  is  not  nearly  so  satisfactory,  comfort- 
able, or  thorough  to  either  examiner  or  patient,  as  the 
lateral  or  Sims'  position.  The  patient  in  the  Sims'  posi- 
tion is  relaxed  and  at  ease,  and  the  parts  presented  in 
such  a  manner  as  to  give  the  clearest  view  and  produce 
most  satisfactory  results. 


Fig.  15. 

Incorrect  Method  of  Digital  Examination. 

This  method  was  formerly  deemed  the  only  proper  method  of  making 
a  digital  examination  of  the  anus  and  rectum.  Contrast  this  with  the 
following  illustration. 

The  wearing  of  a  thin  rubber  finger  cot  is  done  for 
several  reasons.  In  the  first  place,  it  protects  the  wearer 
from  infection.  It  also  prevents  the  soiling  of  the  finger 
with  fecal  material,  pus,  or  discharge  with  their  dis- 


52 


POSTURES  FOR  DIGITAL  EXAMINATION. 


agreeable  odors.  It  does  not  interfere  with  the  sense  of 
touch,  which  can  be  educated  to  extreme  delicacy  even 
with  the  cot.  From  the  patient's  standpoint  it  is  much 
more  desirable — the  smooth  rubber  covering  over  the 
finger  enabling  it  to  enter  much  more  easily  than  the  un- 
protected finger,  and  there  is  no  danger  of  irritating 
sensitive  areas  with  the  finger  nail.  If  one  wishes  to 
make  a  digital  examination,  and  a  finger  cot  is  not  avail- 
able, the  nail  of  the  examining  finger  should  be  trimmed 
close  and  the  crevices  under  and  around  it  filled  by 
scratching  the  surface  of  a  bar  of  soap.  The  rest  of  the 


Fig.   16. 

Correct  Method  of  Digital  Examination. 

With  the  patient  in  the  lateral  or  Sims  position,  the  examiner  standing 
josite  the  sacral  region  of  the  patient,  digital   exploration  of  the  anus 
cl  rectum  can  be  accomplished  with  much  more  thoroughness,  satisfac- 
tion and   comfort   to  both. 


DIGITAL  EXAMINATION.  53 

finger  nail  should  be  covered  with  soap  suds,  vaseline,  or 
whatever  lubricant  is  handy.  After  the  examination,  the 
lubricating  material  should  be  wiped  from  the  finger  with 
a  dry  cloth  or  absorbent  cotton  before  washing  the  hands. 

The  position  of  the  patient  and  the  examiner  as  well  is 
.shown  in  the  accompanying  illustration.  The  protected 
and  lubricated  finger  which  is  usually  the  index  finger  of 
the  right  hand,  is  pressed  against  the  anus  with  its  flexor 
.surface  toward  the  posterior  commissure,  and  the  patient 
is  asked  to  bear  down.  The  finger  is  first  entered  point- 
ing anteriorly  until  the  sphincters  have  been  passed,  and 
ihen  passed  backward  and  upward  in  the  posterior  direc- 
tion. As  the  finger  enters,  it  should  be  gently  turned 
from  side  to  side  sweeping  over  all  the  surfaces  of  the 
anal  canal  and  lower  rectum.  Any  change  from  the  nor- 
mal, soft,  velvety  feeling  of  this  region  such  as  elevations, 
depressions,  or  indurations  should  be  carefully  noted. 
The  location  of  the  feces  is  also  important,  particularly 
where  symptoms  of  interference  with  normal  defecation 
are  presented.  It  is  therefore  important  not  to  give  an 
•enema  before  the  first  digital  examination.  Unless  one 
wishes  to  determine  conditions  high  up  in  the  rectum,  or 
to  make  a  recto-abdominal  examination,  one  should  not 
feel  too  high  in  searching  for  the  source  of  painful  rec- 
tal symptoms.  Most  of  these  diseased  conditions  will  be 
found  within  the  first  two  inches  from  the  anal  outlet. 
Often  in  inserting  the  finger,  the  various  lesions  are 
pushed  up  into  the  rectum  giving  the  impression  that 
they  are  higher  than  they  actually  are.  It  is  with  the 
withdrawal  of  the  finger  therefore  that  more  valuable 
information  is  often  obtained  than  on  its  introduction. 

Where  the  sphincters  are  so  sensitive  or  tightly  con- 


54 


VAGINO-KECTAL    EXAMINATION. 


tracted  as  to  prevent  digital  examination  being  accom- 
plished without  great  pain  to  the  patient,  dilatation  of  the 
sphincters  by  means  of  local  anesthesia  should  be  re- 
sorted to  The  technique  of  local  anesthesia  is  fully  de- 
scribed in  Chapter  XV,  to  which  the  reader  is  referred. 


Fig.  17. 
Vaginal    Eversion    of    the    Anus. 

This  method  is  useful  in  examining  the  anterior  wall  of  the  anus, 
and  lower  rectum  in  female  patients;  particularly  those  who  have  borne 
children  and  who  have  lax  perineums. 

In  women  much  valuable  information  can  be  gained 
oftentimes  by  vagino-rectal  examination  which  is  ac- 
complished either  by  the  index  finger  in  the  rectum  and 
the  thumb  in  the  vagina ;  or  by  using  the  index  finger  of 
the  left  hand  in  the  vagina  while  the  right  is  in  the  rec- 
tum. Often  in  women  where  the  perineum  is  lax,  the  anus 
may  be  everted  by  downward  and  outward  pressure  of 


VAGIXAL    EVERSIOX LITHOTOMY    POSITION. 


55 


the  index  finger  of  the  right  hand  in  the  vagina,  while  the 
anus  is  spread  between  the  index  finger  and  thumb  of  the 
left  hand. 


Fig.    18. 

Another   Method   of    Everting   the  Anal   Tissues   for   Inspection. 
— From   Crossen's  Diagnosis  and  Treatment  of  Diseases  of  Women. 


The  lithotomy  position,  while  in  most  cases  not  nearly 
so  satisfactory  for  complete  ocular  inspection  of  the  ex- 
ternal parts  or  the  use  of  the  anoscope — nor  as  comfort- 
able for  the  patient — has  its  place  in  the  examination  of 
the  patient  suffering  from  ano-rectal  diseases.  If  for 
some  reason  or  other  the  patient  is  not  comfortable  in 
the  lateral  position,  which  will  occasionally  be  the  case 
in  those  who  suffer  from  rheumatism  or  some  other  joint 


56  THE  LITHOTOMY   POSITION. 

affection;  or  on  account  of  an  unusual  amount  of  adipose 
tissue  the  patient's  buttocks  cannot  be  well  separated  in 


Fig.  19. 

Indicating  the  Amount  of  Possible  Eversion  of  Anal  Tissues  When 
the  Pelvic  Floor  is  Lax  as  in  Multiparae. 

— Dudley :      Practice   of    Gynecology. 

the  lateral  position,  the  lithotomy  position  will  be  found 
much  more  satisfactory.  The  patient  is  asked  to  lie  flat 
upon  the  table  after  the  clothing  has  been  removed,  and 
a  sheet  thrown  over  him.  The  knees  are  flexed  upon  the 
thighs  and  the  thighs  upon  the  abdomen  and  the  patient's 
buttocks  pulled  well  down  to  the  edge  of  the  table.  The 
legs  are  kept  in  this  position  either  by  an  assistant  or  by 
the  use  of  a  Kelly  leg  holder  or  Clover's  crutch,  or  by  the 
stirrups  or  leg  holders  which  accompany  the  surgical 


THE   LITHOTOMY   POSITION. 


57 


table  used  by  the  author,  known  as  the  Columbus  table. 
In  this  position  the  perineal  space  and  the  peri-anal  re- 


Fig.  20. 

Posture  and  Method  of  Making  Recto-Abdominal  Bimanual 
Examination. 


Fig.   21. 

Method  cf  Recto- Abdominal  Palpation.   The  Position  of  Both  Hands 
in  Relation  to  the  Uterus  and  Vagina  is  well  shown. 
Montgomery:  Practical  Gynecology. 


58 


BI-MANUAL    EXAMINATION. 


gion  can  be  inspected  and  palpated,  and  in  the  case  of  a 
female  patient,  examination  of  the  genital  organs  carried 
out  at  the  same  time.  In  this  position  also  the  condition 
of  the  prostate  and  seminal  vesicles  of  the  male  can  be 
made  out,  and  oftentimes  the  extent  and  direction  of  a 
fistulous  tract  determined  more  satisfactorily  than  in  the 
lateral  position.  The  condition  of  the  coccyx  can  be  de- 
termined with  the  patient  in  the  lithotomy  position  by 
inserting  one  finger  into  the  rectum  and  the  other  hand 
over  the  region  of  the  coccyx,  or  by  the  insertion  of  the 
forefinger  into  the  rectum  and  the  thumb  of  the  same 
hand  over  the  location  of  the  coccyx  on  the  outside. 


Fig.  22. 

Palpation  of  Rectum  Through  Posterior  Vaginal  Wall. 
Ashton :    Practice    of    Gynecology. 

With  the  patient  in  the  lithotomy  position,  bi-manual 
abdomino-vaginal,  and  abdomino-rectal  examination  are 
accomplished.  It  is  a  good,  safe  plan  to  include  both  of 
these  methods  in  the  routine  examination  of  every  patient 
because  very  frequently  unsuspected  or  beginning  dis- 


ABDOMINO-BECTAL,  PALPATION. 


59 


eased  conditions  in  the  pelvis  and  abdomen  are  discovered 
before  they  have  given  rise  to  subjective  symptoms.  In 
any  case  presenting  the  symptom  of  sacral  backache, 


Fig.  23. 

Method  of  Examining  the  Coccyx  With  One  Hand. 
This  may  also  be  done  with  one  hand  over  the  region  of  the  coccyx 
posterior  to  and  above  the  anus,  and  the  index  finger  of  the  -other  inside 
of   the   rectum. 

Hirst :    Diseases    of   Women. 

weight  in  the  pelvis,  the  passage  of  blood  or  pus  with  the 
stool,  or  diarrhoea — abdomino-rectal  palpation,  with  the 
right  index  finger  inserted  as  high  as  possible  in  the  rec- 
tum, and  the  left  hand  over  the  right  and  left  iliac  fossae 

and  above  the  pubes  is  imperative. 

The  squatting  position,  or  the  position  assumed  by  the 
aboriginal  races  in  defecation,  is  oftentimes  of  great  value 
in  the  diagnosis  of  those  conditions  made  manifest  by 
protrusions  from  the  anal  orifice.  The  patient  is  asked  to 


60  THE  SQUATTING  POSITION. 

remove  his  clothing  and  to  squat  as  if  he  wished  to  de- 
fecate.   It  is  best  to  place  a  shallow  basin  or  receptacle 


Fig.  24. 
Ischio-Rectal  Abscess. 

This  illustration  drawn  from  a  photograph  of  one  of  the  author's 
cases,  besides  showing  the  point  of  swelling  and  fluctuation  of  the 
abscess,  illustrates  the  method  of  bimanual  palpation  in  the  examination 
and  diagnosis  of  the  condition.  At  the  posterior  commissure  of  the 
anus  will  be  seen  a  small  external  hemorrhoid  as  well. 

underneath  him  lest,  during  his  straining  efforts,  feces, 
pus,  blood  or  discharge  may  escape.  The  patient  is  then 
asked  to  bear  down  or  strain ;  when  in  this  position,  pro- 
lapsing internal  hemorrhoids,  polypi,  or  prolapse  of  the 


THE  SQUATTING  POSITION. 


61 


rectum  or  anus,  will  be  brought  into  view  in  a  very  satis- 
factory manner. 


Fig.  25. 

Squatting  Position. 

This  position   shows  the   natural   posture   for   defecation,   and   is  useful 
in  extruding  prolapsing  conditions. 

Drawn    from   a    photograph. 

Before  proceeding  to  internal  inspection,  the  rectum 
should  be  emptied  by  means  of  an  enema  of  soap  suds 
and  water.  If  one's  office  equipment  does  not  include  an 
irrigator,  a  two  quart  fountain  syringe  will  answer  very 
nicely.  Another  very  simple  method  is  to  use  a  three  or 


62 


INTEENAL  INSPECTION. 


four  ounce  soft  tipped,  all-rubber  bulb  syringe,  known  as 
the  ear  and  ulcer  syringe.  With  the  patient  in  the  lateral 
or  Sims'  position,  a  pint  or  more  of  solution  can  be  gently 
injected  and  the  rectum  cleansed  in  a  very  satisfactory 
manner — the  patient  being  allowed  to  rise  and  go  to  the 
toilet  to  expell  it. 


Fig.  26. 

Three   Ounce  All   Rubber   Bulb   Syringe. 

Useful  in  irrigating  and   in   giving  enemas   when  ordinary  irrigator  is 
not  available. 


Fig.  27. 

Posture  and  Method  of   Using  the   Author's  Fenestrated  Anoscope, 
for  Examining  the  Anal  Canal. 


KNEE-SHOULDER    POSITION. 


63 


Internal  inspection  of  the  anus,  rectum,  and  sigmoid  is 
best  accomplished  with  the  patient  in  the  knee-shoulder 
position.  The  patient  who  has  been  lying  in  the  Sims' 
position^  is  asked  to  kneel  on  the  table  and  to  maintain 
the  kneeling  position  while  the  examiner  brings  the  left 
shoulder  down  to  the  table  flush  with  the  knees.  The  pa- 
tient should  not  be  allowed  to  rest  on  the  elbows  as  the 
trunk  must  present  enough  of  an  inclined  plane  to  allow 
atmospheric  dilatation  of  the  rectum,  when  the  examin- 
ing instruments  are  inserted,  and  allow  the  other  abdom- 
inal organs  to  fall  away  from  the  rectum.  The  accom- 
panying illustrations  clearly  show  the  difference  between 
the  correct  and  incorrect  postures. 


Fig.  28. 
Knee-Elbow   Position. 

This  position  is  often  mistakenly  employed  in  proctoscopy,  and  should 
not  be  confused  with  the  knee-shoulder  position,  as  depicted  in  the  fol- 
lowing illustration. 


INTERNAL  INSPECTION. 


Oftentimes  the  internal  opening  of  a  fistula  can  be  de- 
termined by  the  injection  through  its  external  opening  of 
a  solution  of  25  per  cent  peroxide  of  hydrogen.  Upon 
examining  through  the  proctoscope,  while  injecting,  the 
internal  opening  can  be  easily  located  by  the  appearance 
of  the  bubbling  peroxide  solution.  Solutions  of  methy- 
lene  blue  or  milk  of  magnesia  or  bismuth  can  also  be  used 
in  like  manner  for  a  similar  purpose. 


Fig.  29. 
Knee-Shoulder  Position. 

This  is  the  correct  posture  for  proctoscopic  examination.  By  com- 
paring this  with  the  preceding  one,  it  will  be  seen  that  in  the  knee- 
shoulder  position  much  more  of  an  inclined  plane  is  produced.  Note 
the  direction  in  which  the  proctoscope  is  entered. 

For  internal  inspection  of  the  anal  canal,  the  lateral 
Sims'  position  is  sufficient. 

Instruments —The  instruments  required  for  inspec- 
tion of  the  anal  canal  or  anoscopy  are:  a  cylindrical  ano- 


INSTRUMENTS   FOE  ANO3COPY.  65 

scope  whose  internal  opening  is  cut  on  the  slant  and  con- 
taining an  obturator  tapering  to  a  blunt  round  extremity 
(see  figure  30) ;  the  tapering,  adjustable  fenestrated 
anoscope  with  closed  extremity  (see  figure  31);  a  fine 
probe  (see  figure  3:2),  made  of  pure  silver,  and  a  pair  of 
dressing  forceps  (see  figure  33).  An  ordinary  Kelly  ano- 
scope (see  figure  34)  is  also  oftentimes  very  useful. 


Fig.   30. 
Author's  Anoscope  With   Oblique   Opening  and   Slanting  Obturator. 

Bearing  in  mind  from  the  digital  examination,  the 
location  of  the  lesions  in  the  anal  canal,  the  fenestrated 
anoscope  well  lubricated  with  the  opening  turned  so  as 
to  be  opposite  the  lesion  when  entered,  is  pressed  against 
the  anus  and  gently  inserted  while  the  patient  is  bearing 
down  against  it.  If  an  opening  is  detected,  this  may  be 
explored  with  the  soft  silver  probe,  which  may  be  bent 
easily  at  any  angle,  care  being  taken  to  use  no  force  and 
to  handle  it  with  extreme  gentleness  and  delicacy.  In 
some  cases,  the  instrument  with  the  opening  on  the  slant 


66  TECHNIQUE  OF  ANOSCOPY. 

is  used  in  preference,  its  opening  giving  nearly  twice  the 
field  of  the  ordinary  round  opening  of  the  Kelly  instru- 


Fig.  31. 
Author's  Fenestrated  Adjustable  Anoscope. 

This  instrument  is  provided  with  a  closed  extremity;  has  a  fenestrum 
\Y%  in.  long  by  ]/2  in.  wide;  can  be  revolved  so  that  the  fenestrum  can 
be  placed  at  any  angle  in  relation  to  the  handle,  and  on  account  of  the 
peculiar  shape  of  the  ferrule  at  the  proximal  end  of  the  fenestrum,  is 
self-retaining. 

ment.    The  Kelly  anoscope,  however,  is  useful  in  expos- 
ing conditions  which  prolapse — the  patient  being  asked 


Fig.   32. 
Silver  Probe. 

This  type  of  probe,  equipped  with  a  proper  handle  and  made  of  pure 
annealed  silver,  is  the  best  for  use  in  rectal  examination.  It  is  made 
in  many  sizes. 

to  strain  and  bear  down  while  the  instrument  is  being 
withdrawn. 

By  so  doing,  prolapsing  hemorrhoids,  prolapsus-ani,  or 
recti,  polypi,  or  papillae  are  brought  out  into  view.  If 
the  view  is  obscured,  at  any  time,  a  bit  of  cotton  should 
be  taken  up  with  the  dressing  forceps  to  cleanse  the  parts. 


PROCTOSCOPY.  67 

The  knee-shoulder  position  is  by  far  the  most  satisfac- 
tory in  the  author's  experience  for  examination  of  the 


Fig.  33. 

Long  Alligator  Forceps. 

These  are  made  in  different  sizes  raiging  from  9  to  14  inches  in  length 
and  are  very  useful  in  proctoscopic  and  sigmoidoscopic  examination. 

rectal  cavity  and  most  of  the  sigmoid.     Not  only  does 
the  atmospheric  pressure  balloon  out  the  rectum,  to  its 


Fig.  34. 
Kelly  Anoscope. 

Useful   in   prolapsing   conditions. 


fullest  capacity,  but  this  position  also  removes  the  pres- 
sure of  other  abdominal  organs  from  the  rectum  by  al- 
lowing them  to  fall  away. 


68 


PKOCTOSCOPY    WITHOUT    INSTKUMENTS. 


The  only  instruments  required  for  proctoscopy  or  ocu- 
lar inspection  of  the  rectal  cavity  are,  a  cylindrical  proc- 
toscope, from  four  to  six  inches  in  length  and  from  three- 
quarters  to  seven-eighths  of  an  inch  in  diameter,  and  a 


Fig.  35. 
Bivalve   Rectal   Speculum. 

This  is  an  instrument  formerly  used  for  rectal  examinations  but  which, 
in  the  author's  opinion,  has  absolutely  no  place  in  modern  methods  of 
examination.  It  should  be  used  in  operative  work,  arid  only  when  the 
patient  is  under  general  anesthesia. 

pair  of  long  alligator  forceps.  In  an  emergency,  a  very 
fair  inspection  of  the  rectal  cavity  may  be  had  without  any 
instruments  whatever.  The  technique  of  proctoscopy 
without  instruments,  is  as  follows:  With  the  patient  in 
the  knee-shoulder  position,  the  index  finger  of  the  right 
hand,  protected  by  a  finger  cot,  and  well  lubricated,  is 
gently  inserted  and  the  sphincter  massaged;  then  the 
index  finger  of  the  left  hand,  similarly  protected  and  lub- 
ricated, is  introduced  back  to  back  with  the  finger  in  the 
rectum.  The  introduction  of  the  second  finger  should. 
be  done  slowly  and  gently  and  with  a  massage  motion. 
When  it  has  been  introduced  to  an  equal  depth  with  its 
fellow,  that  is,  up  to  the  second  joint  of  the  finger,  the 


TECHNIQUE   OP  PEOCTOSCOPY.  69 

fingers  should  be  gently  separated.  The  atmospheric  air 
then  rushes  in  with  an  audible  hiss,  and  the  rectum  bal- 
loons out  so  that  it  can  be  examined  with  the  aid  of  the 
electric  headlight  or  reflected  light  from  the  head  mirror. 


Fig.   36. 
Wales  Rectal  Bougie. 

This  is  made  of  flexible  rubber  and  provided  with  a  canal  through 
which  irrigation  may  be  given  and  which  allows  the  entrance  of  at- 
mospheric air  and  escape  of  gas  during  its  introduction.  There  are 
twelve  different  sizes. 

With  this  method,  however,  one  cannot  see  behind  the 
rectal  valves  or  folds  of  Houston,  and  it  is  only  of  value 
where  a  suitable  examining  instrument  is  not  at  hand  and 
the  lowermost  portion  of  the  rectal  cavity  only  is  to  be 
explored. 

The  technique  of  proctoscopy  is  as  follows:  With  a 
proctoscope  whose  outside  diameter  does  not  exceed  the 
diameter  of  the  operator's  index  finger,  all  parts  of  the 
rectal  cavity  can  be  successfully  explored,  and  its  intro- 
duction causes  no  more  pain  or  discomfort  than  digital 
examination.  The  instrument  used  by  the  author  is  a 
modification  of  that  devised  by  T.  C.  Martin.  It  is  five 
and  one-half  inches  long  from  the  edge  of  the  flange  to 


70  TECHNIQUE  OF  PROCTOSCOPY. 

the  tip  of  the  obturator.  Its  outside  diameter  is  three- 
quarters  of  an  inch.  It  is  provided  with  an  obturator 
made  of  metal,  with  a  conical  extremity  which  fits  it 
very  snugly.  The  obturator  is  channeled  so  as  to  allow 
the  ingress  of  air  during  its  introduction.  With  the  pa- 
tient in  the  knee-shoulder  position,  the  well  lubricated 
proctoscope  is  pressed  against  the  anus,  pointing  in 


Fig.   37. 

Author's  Modification  of  the  Martin  Proctoscope. 
Provided   with   a   metal   obturator   with   conical    extremity,   which    con- 
tains an  air  vent  running  through  its  entire  length.     It  is  ^  of  an  inch 
in    diameter    and    six    inches    long. 

the  direction  of  the  patient's  umbilicus,  and  the  patient 
asked  to  bear  down,  as  in  the  act  of  defecation.  While 
he  is  doing  so,  the  proctoscope  is  inserted  gently,  first 
downward  and  forward,  until  the  anal  canal  has  been 
passed;  when  it  is  tilted  upward  and  backward  and  the 
rectal  cavity  is  entered  without  difficulty.  By  asking 
the  patient  to  bear  down  during  the  introduction  of  the 
instrument,  the  patient  forces  his  anus  down  over  the 
proctoscope,  as  it  were,  and  introduction  is  accomplished 


TECHNIQUE  OF  PROCTOSCOPY.  71 

with  much  ease.  Holding-  the  proctoscope  in  the  left 
hand,  the  obturator  is  withdrawn  with  the  right.  Inspec- 
tion of  the  entire  rectal  cavity  can  then  be  accomplished 
with  as  much  ease  and  completeness  as  the  examination 
of  the  nose  or  throat.  The  proctoscope  should  always 
be  entered  to  its  fullest  length  before  the  obturator  is 
withdrawn. 

After  having  examined  the  uppermost  part  of  the 
rectum,  noting  the  appearance  and  condition  of  the  recto- 
sigmoidal  juncture,  it  is  slowly  withdrawn,  the  examin- 
er in  the  meanwhile  noting  the  condition  of  the  lining 
membrane  of  the  rectum,  the  rectal  valves,  and  anal  canal 
until  the  instrument  is  completely  withdrawn.  If,  upon 
the  withdrawal  of  the  obturator  the  opening  of  the  proc- 
toscope seems  closed  by  a  wall  of  rectal  mucous  mem- 
brane, by  manipulating  the  instrument  so  that  its  inner 
extremity  is  moved  to  one  side  or  the  other,  the  obstruc- 
tion will  often  be  found  to  be  one  of  the  rectal  valves,  or 
folds  of  Houston;  and  on  pushing  this  to  one  side  with 
the  instrument,  a  new  field  is  exposed  to  view.  With  the 
proctoscope  in  position,  the  size,  density  and  thickness  of 
the  rectal  valves  can  be  noted  by  means  of  a  probe  or  ap- 
plicator bent  at  a  right  angle;  ulcerations  of  the  rectal 
wall,  their  extent  and  severity  noted;  the  condition  of 
the  circulation  of  the  rectum ;  the  presence  of  polypi — in 
fact,  any  deviation  from  the  normal  smooth  pinkish  red 
appearance  of  the  mucous  membrane  of  the  normal  rec- 
tum easily  made  out  by  this  method  of  examination. 
While  the  proctoscope  is  in  position,  local  applications 
to  diseased  areas,  sprays,  insufflations  and  other  thera- 
peutic measures,  when  indicated,  may  be  carried  on 
under  the  direct  guidance  of  the  eye.  The  alligator  for- 


72  EXAGGERATED  LITHOTOMY  POSITION. 

ceps  are  useful  for  swabbing  out  the  rectum  and  obtain- 
ing tissue  for  microscopical  examination. 

The  exaggerated  lithotomy  position  also  sometimes 
known  as  the  genito-urinary  position,  is  very  useful 
when  it  is  necessary  to  examine  the  sigmoid  flexure.  This 
position  is  secured  by  putting  the  patient  into  the  litho- 
omy  position  as  above  described,  and  then  slowly  lower- 


Fig.  38. 
Exaggerated  Lithotomy  Position. 

.  Illustrating  posture  of  the  patient  and  technique  of  the  introduction 
of  the  sigmoidoscope. 

ing  the  head  of  the  table  so  as  to  leave  the  buttocks 
somewhat  higher  than  the  patient's  shoulders.  This  puts 
the  patient  into  a  sort  of  semi-Trendelenburg  position 
with  the  thighs  and  knees  flexed.  In  this  position  it  will 
be  found  comparatively  easy  to  introduce  the  sigmoido- 


TECHNIQUE   OF    SIGMOIDOSCOPY. 


73 


scope  and  secure  atmospheric  dilatation  of  the  sigmoid 
flexure. 

The  instruments  necessary  for  the  ocular  inspection 
of  the  sigmoid  flexure  or  sigmoidoscopy,  are  sigmoido- 
scopes  varying  in  length  from  nine  to  fourteen  inches, 
and  from  three-quarters  to  an  inch  in  circumference,  and 


Fig.  39. 

Kelly  Sigmoidoscope. 
This  is  made  hi  sizes  varying  from  eight  to  fourteen  inches  in  length. 

the  long  alligator  forceps.     The  instrument  devised  by 
Kelly  is  very  serviceable,  but  its  introduction  has  been 


Fig.  40. 

Sigmoidoscope  Provided  With  the  Author's  Tilting  Obturator. 
The  tilting  obturator  is  of  value  in  the  insertion  of  the  Sigmoidoscope, 
allowing  it  to   round  the  sacral  curve   with  greater  facility. 


74 


ATEESIA  ANI  VAGINALIS. 


made  much  easier  by  the  use  of  an  obturator  whose  pro- 
jecting extremity  tilts  so  as  to  allow  of  easier  introduc- 
tion in  rounding  the  curve  of  the  sacrum.  Tuttle  has 
devised  such  an  instrument  as  has  also  the  author.  The 
only  other  instrument  required  is  a  long  alligator  for- 


Fig.  41. 
Atresia  Ani  Vaginalis  (Complete.) 

Photograph  of  author's  case.  This  illustrates  a  case  of  complete 
absence  of  the  anus  with  the  rectum  emptying  itself  through  the  vagina. 
This  patient  was  25  years  old  and  did  not  know  until  shortly  before 
consulting  the  author,  that  she  was  different  from  other  people.  She 
had  partial  control  of  her  fecal  movements  by  an  over-development  of 
her  sphincter-vaginae.  At  the  normal  location  of  the  anus  was  found  a 
rudimentary  external  sphincter.  The  case  was  operated  upon  by  the 
author,  the  vaginal  opening  closed  and  the  rectum  brought  down  to  the 
normal  anal  site,  with  the  result  that  the  patient  has  an  apparently  nor- 
mal anus  with  good  control.  The  above  photograph  well  shows  the 
septum  separating  the  rectal  opening  of  the  vagina  from  the  upper 
vaginal  canal. 


ATRESIA  ANI  VAGINALJS. 


75 


ceps  for  use  in  swabbing  out  the  sigmoid  cavity  and  for 
the  purpose  of  removing  tissue  for  microscopical  exam- 
ination. Sigmoidoscopy  may  be  accomplished  with  the 
patient  in  the  knee-shoulder  position,  but  much  more 
satisfactory  results  are  obtained  from  the  employment 
of  the  exaggerated  lithotomy  position. 


Fig.  42. 

Atresia  Ani  Vaginalis  (Incomplete.) 

This  photograph,  taken  from  one  of  the  author's  cases,  seen  in  con- 
sultation, differs  from  the  preceding  in  that  while  the  patient  passed 
her  stools  through  the  vaginal  opening,  the  anus  was  not  entirely 
occluded,  there  being  a  small  ano-vaginal  fistula.  This  patient  was  23 
years  of  age  and  had  a  remarkably  well  developed  sphincter  vaginae 
and  was  able  to  well  control  her  fecal  movements  through  the  vulvar 
orifice.  This  case  was  likewise  operated  and  the  rectum  restored  to 
its  normal  position  with  a  good  functional  and  cosmetic  result.  The 
external  sphincter  muscle  was  more  fully  developed  in  this  case  than 
in  the  preceding  one,  and  control  followed  much  more  rapidly. 


76  CONGENITAL    MALFORMATIONS. 

Before  leaving  the  subject  of  examination  of  the  pa- 
tient, the  author  would  advise  his  readers  to 
carefully  examine  every  patient  to  make  sure  that  there 
is  not  present  some  congenital  defect  or  malformation 
of  the  anus  or  rectum.  Every  infant  at  birth  should 
be  examined  by  the  attending  obstetrician  to  make  sure 
that  the  ano-rectal  canal  is  patent,  as  imperforate  anus, 
while  said  to  occur  but  once  in  10,000  cases,  seems  to 
the  author,  in  his  own  experience  and  that  of  his  profes- 
sional friends  with  whom  he  has  consulted,  to  have  oc- 
curred apparently  more  frequently.  If  imperforate  anus 
is  not  recognized,  the  child  will  either  die  in  a  few  hours 
or  days  if  the  condition  is  not  remedied,  and  even  then 
the  operation  is  attended  with  a  very  high  mortality; 
or  nature  will  occasionally  form  a  new  outlet  for  the 
escape  of  the  feces.  In  girls  this  happens  more  frequent- 
ly through  the  vagina  and  in  male  infants  through  the 
scrotum,  bladder  or  urethra.  Two  cases  have  come  under 
the  author's  notice  (See  Figs.  41  and  42),  in  which  young 
women  were  allowed  to  grow  to  the  ages  of  23  and  25 
respectively  with  congenital  defects  so  serious  as  to  pre- 
clude the  possibility  of  marriage  until  remedied.  In  one 
(Fig.  41)  there  was  a  complete  absence  of  an  anal  ori- 
fice, and  in  the  other  (Fig.  42),  an  aperture  about  one- 
fifth  of  the  normal  size.  In  both  cases,  defecation  took 
place  through  the  false  opening  into  the  vagina. 


CHAPTER  IV. 

CONSTIPATION  AND  OBSTIPATION. 

Constipation  may  be  defined  as  the  voiding  of  insuf- 
ficient amounts  or  the  abnormally  prolonged  retention  of 
fecal  material  in  the  intestinal  canal.  Constipation  in 
contradistinction  to  obstipation,  is  due  to  purely  func- 
tional diseases  or  conditions  of  some  portion  of  the  intes- 
tinal tract.  Obstipation,  on  the  other  hand,  is  a  condition 
in  which  there  is  a  sufficient  quantity  of  fecal  material, 
and  a  normal  functional  activity;  but  in  which  some  de- 
formity, growth,  flexion,  constricture,  or  foreign  body  in 
the  intestinal  canal  offers  a  mechanical  obstruction  to  the 
passage  of  the  fecal  current.  These  two  conditions  are 
so  frequently  confounded  in  the  mind  of  the  average  prac- 
titioner that  the  distinction  must  be  always  born  in  mind ; 
for  the  treatment  of  these  conditions,  while  they  may 
present  similar  symptoms,  is  entirely  different. 

Constipation  is  really  but  a  relative  condition.  One 
individual  may  have  two  or  three  passages  daily  and  still 
be  constipated,  while  another  individual  may  have  but 
one  passage  a  week  and  not  be  constipated. 

Constipation  in  itself  is  not  a  disease  but  merely  a 
symptom  of  a  great  many  diseased  conditions,  but  is  so 
often  the  only  apparent  symptom 'of  which  the  patient 
complains,  that  its  discussion  as  a  separate  disease  entity 
is  deemed  advisable. 


78  PHYSIOLOGY    OF   DEFECATION. 

Obstipation  is  caused  by  such  mechanical  conditions 
as  malformations  of  the  intestinal  canal,  stricture,  ad- 
hesions, pressure  from  the  pregnant  uterus  and  the  va- 
rious abdominal  tumors,  angulation,  enteroptosis,  steno- 
sis of  the  ileo-cecal  valve,  fecal  impaction,  foreign  bodies, 
hypertrophied  rectal  valves,  prolapsus,  large  hemor- 
rhoids, enlarged  prostate  and  hypertrophied  sphincters. 

Chronic  constipation  is  a  condition  which  affects  a 
large  proportion  of  all  the  patients  treated  by  every  prac- 
titioner of  medicine.  *  It  is  a  condition  which  is  brought 
about  by  our  modern,  so-called  "strenuous  life."  We 
find  it  in  the  infant  and  in  the  nonagenarian.  It  is  due  to 
a  great  many  factors,  and  in  order  that  one  may  under- 
stand it  more  fully,  I  will  review  some  points  in  the 
physiology  of  peristalsis  and  defecation. 

Physiology  of  Defecation.  Up  to  the  last  moment  at 
which  the  fecal  mass  is  expelled  from  the  anus,  the  in- 
gested materials  are  carried  through  the  intestinal  tract 
by  what  is  known  as  peristaltic  action.  After  the  food 
has  entered  the  stomach  and  the  albuminoids  converted 
into  peptones,  it  passes  through  the  pylorus  into  the 
small  intestine.  As  the  stomach  contents  pass  through 
the  pylorus,  they  are  acid.  The  secretions  in  the  small 
bowel — the  bile  and  the  pancreatic  juice,  being  alkaline ; 
when  the  acid  stomach  contents  are  poured  into  the  small 
intestine,  coming  in  contact  with  the  alkaline  intestinal 
secretions,  a  stimulation,  or  irritation  is  caused,  which 
produces  a  wave  of  muscular  contraction,  or  peristalsis. 

At  the  same  time  that  the  chemical  reaction  of  the  acid 
stomach  contents  upon  the  alkaline  contents  of  the  intes- 
tine is  going  on,  certain  gases  are  created.  These  gases 
are  not  abnormal  but  serve  a  most  useful  purpose.  It  is 


PHYSIOLOGY    OF   DEFECATION.  79 

when  they  are  in  too  great  quantities  and  too  severe  peris- 
talsis and  consequent  too  great  distension  of  the  intestinal 
canal  ensue;  that  they  are  harmful.  They  then  cause 
atony  or  paralysis  of  the  circular  muscle  fibres  and  loss 
of  tone.  These  gases  are  largely  reabsorbed  by  the  blood 
vessels  or  discharged  with  the  feces.  If  these  gases  in 
their  downward  passage  meet  any  obstruction,  they  are 
forced  backward  into  the  stomach  and  are  discharged 
in  this  direction. 

Another  important  source  of  stimulation  to  the  coats 
of  the  bowel  is  the  harsh,  indigestible  particles  of  food 
which  are  not  acted  upon  by  the  digestive  secretions. 
These  also  irritate,  and  stimulate  the  contraction  of  the 
circular  muscular  fibres  in  the  small  intestine.  Of  no 
small  importance  is  the  stimulus  caused  by  the  to  and  fro 
movement  imparted  to  the  bowel  by  the  action  of  respira- 
tion. The  excursions  of  the  diaphragm  upward  and 
downward  impart  to  the  small  bowel  in  particular,  and 
also  to  the  transverse  colon,  a  movement  which  stirs  up 
and  churns,  as  it  were,  the  intestinal  contents.  It  changes 
the  position  of  the  bowel  and  helps  to  keep  the  intestinal 
contents  on  the  move.  It  can  be  easily  seen  how  anything 
which  constricts  and  prevents  the  full  expansion  of  the 
chest  will  interfere  with  the  intestinal  functions  and 
assist  in  causing  constipation. 

The  intestinal  contents  are  fluid  until  they  reach  the 
ileo-cecal  valve.  In  the  cecurn  they  become  less  fluid  and, 
having  to  travel  against  the  force  of  gravity,  their  move- 
ment in  the  large  bowel  is  checked.  Staying,  as  they  do, 
in  this  portion  of  the  bowel  for  some  time,  the  fluid  con- 
stituents are  gradually  absorbed,  and  the  nearer  to  the 
sigmoid  the  feces,  the  more  solid  they  become.  The  mucous 


80  ETIOLOGY. 

membrane  of  the  colon  is  thicker  and  not  so  sensitive  as 
that  of  the  small  bowel  and  requires  more  stimulation, 
consequently  the  stools  are  more  solid  in  this  portion  of 
the  bowel.  If  however,  too  much  vegetable  fibre  and  in- 
digestible material  is  present,  the  colon  tends  to  become 
over-stimulated,  over-distended,  and  atonic;  the  fecal 
mass  moves  very  slowly  and  chronic  constipation,  and 
sometimes  fecal  impaction  results.  The  fecal  material 
when  it  reaches  the  siginoid,  rests  until  ready  to  be 
passed  out  through  the  rectum  and  anus,  as  a  fecal  move- 
ment. 

Causes.  It  can  readily  be  seen  that  anything  which 
interferes  with  the  proper  development  and  exercise  of 
the  intestinal  muscle  layers  will  interfere  with  the  proper 
movement  of  the  intestinal  contents  and  with  expulsion 
at  the  proper  time.  In  the  first  place,  enough  fluid  must 
be  taken  into  the  system  daily  to  keep  the  intestinal  con- 
tents in  solution  and  to  properly  supply  the  various  or- 
gans of  the  body.  People  who  do  not  drink  enough 
water  suffer  from  constipation  because  of  the  re-absorp- 
tion of  fluids  from  the  intestinal  tract  and  consequent 
hard  and  dry  stools.  People  who  drink  great  quantities 
of  water  with  their  meals  drown  their  stomach  contents ; 
undigested  particles  of  food  are  sent  through  the  pylorus 
with  gushes  of  greatly  diluted  gastric  juice;  the  feeble 
acid  reaction  of  this  mixture  does  not  cause  the  proper 
reaction  with  the  alkaline  intestinal  contents ;  the  proper 
amount  of  gases  is  not  evolved  and  quantities  of  irritat- 
ing food  particles  are  passed  down  the  small  bowel.  This 
is  another  cause  of  loss  of  tone. 

It  is  a  well  known  fact  that  carnivorous  animals  are 
constipated  while  the  herbivorous  animals  have  full  and 


ETIOLOGY.  81 

frequent  bowel  movements.     It  therefore  behooves  us 
to  see  that  a  sufficient  quantity  of  vegetable  material 
which  will  leave  undigested  fibre  in  sufficient  and  not 
too  great  quantities,  such  as  corn,  celery,  beet  tops,  let- 
tuce, spinach,  water  cress,  endive,  kale,  and  other  greens, 
is  incorporated  into  our  daily  regimen.     It  should  also 
contain  a  sufficient  quantity  of  mineral  salts,  which  are 
natural  laxatives.     It  should  contain  sweets  within  rea- 
sonable limits,  because  of  the  gas  development  which 
goes  with  them,  and  the  fact  that  carbon  dioxide  gas  is 
one  of  our  best  laxatives  should  not  be  forgotten.    Above 
all,  the  food  of  the  individual  must  not  be  concentrated; 
it  must  give  sufficient  bulk  to  the  stool  so  that  it  will 
properly  fill  and  distend  the  gut,  give  it  work  to  do 
and  produce  the  proper  mechanical  stimulus  to  cause 
contraction.     The  value  of  whole  wheat  bread  and  bran 
lies  in  the  quantity  of  cellulose  in  the  husk,  which  is  a 
very  important  element.     People  who  eat  too  fast  do 
not  properly  masticate  their  food,  causing  improper  di- 
gestion with  improper  bowel  contents,  and  have  improper 
stimuli  to  peristalsis  and  consequently  improper  stools. 
Outside  of  dietetic  error,  the  most  important  cause  of 
constipation  is  neglect.    The  school  child  hears  the  call 
of  nature,  the  fecal  mass  is  ready  to  be  extruded,  he  is 
receiving   powerful    stimuli    for   the    dilatation    of   the 
sphincters  and  the  expulsion  of  his  bowel  contents;  but 
in  our  modern  schools,  the  lesson  hour  is  more  import- 
ant than  the  functions  of  nature!     The  child  is  not  al- 
lowed to  go  and  relieve  himself.    He  restrains  nature's 
efforts ;  the  desire  passes  away.    The  continuance  of  this 
performance  day  after  day  soon  makes  the  child  a  chron- 
ically constipated  child. 


82  ETIOLOGY. 

While  peristalsis  is  involuntary,  in  the  vast  majority 
of  people  the  voluntary  control  over  the  sphincter  is 
normally  sufficient  to  withstand  it.  The  strong  expul- 
sive efforts  soon  weaken  when  retarded  by  a  tightly 
contracted  sphincter,  and  shortly  the  constipated  habit 
is  induced.  The  young  girl  in  society  is  taken  with  a 
desire  to  move  her  bowels  and  either  because  the  time  is 
not  convenient  and  she  restrains  nature's  efforts,  the  de- 
sire soon  passes  away  and  she  is  constipated ;  or  she  may 
be  willing  to  satisfy  nature's  desire,  but  in  order  to  reach 
the  toilet  room  she  must  perhaps  pass  through  a  crowded 
room,  and  false  modesty  prevents  her  from  allowing  her 
friends  to  see  her  go  in  the  direction  of  the  toilet  room. 
A  very  important  provision  in  architecture  of  homes  and 
institutions  should  be  the  placing  of  the  toilet  room  in 
such  an  inconspicuous  place  that  a  person  may  reach  the 
same  without  being  subjected  to  the  gaze  of  others. 

The  business  man,  the  traveller,  the  physician,  the 
school  teacher,  the  professional  man — all  refuse  to  obey 
nature's  call  because  the  time  is  not  convenient,  and  thus 
because  we  have  not  time  to  move  our  bowels  when  they 
want  to  be  moved,  we  have  become  a  constipated  nation ! 
I  think  this  neglect  and  indifference  is  the  most  impor- 
tant cause  of  constipation. 

Another  contributing  cause  to  the  voluntary  repres- 
sion of  defecation  is  the  fact  that  in  institutions,  and  in 
large  buildings,  there  are  not  enough  toilet  rooms  for  the 
number  of  inmates.  Where  one  has  to  wait  long  for  his 
turn,  the  desire  is  soon  lost. 

The  shape  of  the  toilet  seat  and  its  height  from  the 
floor  are  all  of  importance  in  the  production  of  a  good 
stool.  The  seat  should  be  so  made  that  the  person  using 


DIAGNOSIS  AND  TREATMENT.  83 

it  is  in  the  squatting  position  with  the  buttocks  well 
separated  so  as  to  allow  the  free  excursion  upward 
and  downward  of  the  muscles,  which  go  to  form  the  pel- 
vic floor,  and  the  full  action  of  all  the  other  muscles  in- 
volved in  defecation  brought  into  play.  People  leading 
sedentary  lives,  who  do  not  get  sufficient  exercise,  of 
course,  are  constipated,  for  exercise  is  one  of  the  im- 
portant factors  in  keeping  all  bodily  functions  normal. 
There  are  many  other  causes  which  may  contribute  to 
the  production  of  constipation  in  individual  cases,  but 
those  mentioned  are  the  most  important,  and  the  most 
common. 

Diagnosis  and  Treatment.  When  the  bowel  has  be- 
come atonic,  remedies  to  restore  its  tone  must  be  em- 
ployed. In  the  treatment  of  acute  constipation,  cathartic 
drugs,  suppositories,  enemata,  all  have  their  proper 
place;  but  the  victim  of  chronic  constipation  should  no 
more  be  made  a  drug  fiend  than  the  victim  of  chronic 
appendicitis.  Instead  of  causing  irritating,  irregular 
erratic  and  violent  peristaltic  movements  at  certain  times 
during  the  day;  and  instead  of  changing  from  one  ca- 
thartic to  another  and  increasing  the  dosage — instead 
of  taking  away  the  work  of  the  bowel  by  flushing  with 
enemata — we  should  strive  to  bring  that  bowel  back  to 
its  normal  tone  by  imitating  nature's  methods.  The  only 
place  for  a  cathartic  in  the  treatment  of  chronic  consti- 
pation is  at  the  beginning  of  the  treatment. 

When  a  patient  consults  you,  complaining  of  infre- 
quent or  insufficient  bowel  movements,  the  first  thing  to 
do  is  to  make  a  diagnosis  between  constipation  and  ob- 
stipation. The  patient  should  be  examined  carefully,  his 
abdomen  should  be  palpated  thoroughly;  the  female  pa- 


84  TREATMENT. 

tient  should  have  a  bimaimal  examination ;  the  male  pa- 
tient should  have  the  genito-urinary  organs  examined,  as 
many  cases  of  constipation  are  reflexes  from  bladder 
and  prostatic  conditions.  The  rectum  and  sigmoid  should 
be  thoroughly  explored  and  a  complete  proctoscopic  ex- 
amination with  the  patient  in  the  knee-shoulder  position 
is  imperative  in  every  patient  complaining  of  impeded 
fecal  movements.  After  you  have  satisfied  yourself  that 
you  have  a  case  of  constipation,  and  not  obstipation,  to 
deal  with,  and  after  carefully  questioning  your  patient 
as  to  habits,  diet  and  previous  history;  the  question  of 
treatment  presents  itself. 

Dietetic  errors  should  be  corrected  and  the  patient  in- 
structed as  to  the  time  and  the  quantity  and  the  kinds  of 
food  to  take.  If  he  is  not  able  to  properly  masticate  his 
food,  he  should  consult  his  dentist.  The  teeth  should  be 
put  into  perfect  shape.  He  should  be  instructed  to  drink 
from  six  to  eight  glasses  of  water  in  every  twenty-four 
hours — the  first  glass  on  rising,  the  last  glass  on  retiring. 
He  should  drink  plenty  of  water  between  meals,  but  very 
sparingly  with  meals.  He  should  be  instructed  to  eat  a 
sufficient  amount  of  vegetable  foods  and  not  to  remove 
outside  coverings  of  such  fruits  as  pears,  apples  and 
peaches,  before  eating  them.  He  should  be  instructed  to 
take  out-door  exercise:  to  play  tennis;  to  play  golf;  to 
go  horse-back  riding  or  bicycle  riding;  to  take  long 
walks.  He  should  take  breathing  exercises,  and  should 
develop  his  abdominal  muscles. 

Any  local  condition,  such  as  hemorrhoids,  which  of 
themselves  do  not  cause  constipation  but  are  caused  by 
constipation,  but  by  their  presence  prevent  natural  move- 
ments, should  be  corrected.  Fissures,  ulcers,  or  excoria- 


TREATMENT.  80 

tions  of  the  anus,  should  be  remedied  by  surgical  means 
or  treated  locally.  Proctitis  should  be  relieved  by  the 
proper  sprays  and  medications  applied  locally.  Run 
down  patients  should  receive  in  addition,  massage  from  a 
properly  qualified  masseur.  The  abnormally  tight 
sphincter  should  be  dilated  or  given  vibratory  massage, 
and  the  atonic  lower  bowel  should  be  properly  massaged. 

A  great  many  drugless  methods  of  treating  constipa- 
tion have  been  offered  to  the  medical  profession.  All 
kinds  of  electric  and  external  massage,  cannon-balls, 
gymnastics,  vibratory  massage,  and  what  not,  have  all 
been  tried,  and  while  satisfactory  results  have  been  ob- 
tained from  each  of  them  in  certain  cases,  there  still 
seems  something  to  be  desired  in  the  successful  treat- 
ment of  chronic  constipation. 

The  direct  stimulation  of  the  atonic  sigmoid  and  rec- 
tum by  means  of  mechanical  dilatation  has.  up  to  the 
present  time,  given  the  best  results.  Rubber  bags,  which 
have  been  introduced  through  the  proctoscope  into  the 
sigmoid  and  inflated,  have  been  used  by  Turck  and  others 
with  excellent  results.  Tamponing  the  rectum  and  sig- 
moid with  cotton,  wool,  or  gauze,  as  advocated  by  Mac- 
Millan,  has,  by  its  mechanical  irritation  of  the  mucous 
coats  of  the  bowel  and  its  simulating  the  normal  bowel 
contents  produced  satisfactory  evacuation.  The  incon- 
venience of  carrying  around  a  tampon  or  inflated  bag 
in  the  rectum  or  sigmoid  for  from  four  to  six,  or  even 
twelve  hours,  has,  however,  militated  somewhat  against 
the  more  general  use  of  these  methods.  W.  Teachnor,  of 
Columbus,  0.,  has  successfully  treated  a  number  of  cases 
by  simple  inflation  of  the  rectum  and  sigmoid  by  the  en- 


86  AUTHOR'S  METHOD  OF  RECTAL  MASSAGE. 

trance  of  air  through  the  proctoscope,  while  the  patient 
is  in  the  knee-shoulder  position. 

Author's  Method.  The  author  has  devised  a  very  sim- 
ple pneumatic  dilator  for  accomplishing  this  distention, 
and  has  achieved  very  happy  results  from  its  use.  No 
great  originality  is  claimed  for  this  device.  It  consists 
simply  of  a  specially  devised  rubber  bag  with  a  stem, 
which  is  slipped  over  the  distal  end  of  a  Wales  bougie 


Fig.  43. 

The  Author's  Pneumatic  Rubber  Dilating  Rectal  Massage  Bag 
Equipped  With  a  Hand  Bulb. 

(No.  3-5),  the  Wales  bougie  being  canaled  (Fig.  43)  and 
containing  an  air  vent  in  the  handle  which  is  covered 
by  the  finger  until  the  air  is  to  be  expelled.  Compressed 
air  at  a  low  pressure  (one  to  three  pounds)  is  allowed 
to  slowly  enter  the  bag,  and  distension  to  any  desired  ex- 
tent is  produced.  By  means  of  an  ordinary  cut-off  valve 
this  distension  can  be  easily  regulated.  Where  the  com- 


TECHNIQUE  OF  RECTAL  MASSAGE. 


87 


pressed  air  apparatus  is  not  convenient,  an  ordinary 
atomizer  bulb  or  a  small  bicycle  pump  can  be  utilized. 

The  patient  is  placed  in  the  Sims  position.  The  bag  is 
lubricated  and  deflated,  is  twisted  around  itself  as  an 
umbrella  is  rolled  on  its  handle,  and  passed  upward  into 
the  rectum  following  the  backward  curve  of  the  sacrum, 
then  into  the  sigmoid  to  any  desired  height. !  The  Wales 
bougie  being  firm  enough  to  carry  the  bag  up  into  the  sig- 
moid, and  yet  being  flexible,  does  not  create  any  dis- 


Fig.  44. 
Author's  Rubber   Dilating   Rectal   Massage  Bag. 

a.  Bag  deflated. 

b.  Showing   the    amount   of   inflation   necessary   in   the   average    case. 

comfort  or  do  any  injury  in  its  passage ;  and  it  obviates 
the  use  of  the  proctoscope  in  its  introduction.  When  the 
bag  is  in  position,  it  is  slowly  inflated  until  the  patient 
complains  of  either  fullness  or  slight  crampy  pain,  or 
a  desire  to  move  the  bowels.  The  air  is  allowed  to  escape 
by  removing  the  finger  from  the  air  vent  in  the  handle 


88  TECHNIQUE  OF  RECTAL  MASSAGE. 

of  the  bougie,  and  after  an  interval  of  five  or  ten  seconds, 
it  is  again  inflated  to  the  point  of  tolerance;  the  cut-off 


Fig.  45. 
Position  of  Patient  and  Operator  for  the  Author's  Method  of  Rectal 

Massage. 

This  is  the  best  position   for  both  the  patient  and  operator  in  treating 
chronic  constipation  with   the   authors   dilating   rectal  massage  bag. 

valve  is  disengaged  and  the  opening  in  the  bougie  is 
closed  with  the  thumb,  and  where  the  hand-bulb  is  used, 
the  air  vent  in  handle  of  the  bougie  is  closed  with  the 
finger-tip;  and  then  by  a  to  and  fro  motion,  the  appar- 
atus is  gently  and  slowly  withdrawn.  This  method  of 
removing  the  apparatus  is  important  as  it  also  gently 
dilates  the  sphincter  muscles. 

This  treatment  is  repeated  daily  for  from  five  days  to 
a  week,  and  usually  after  the  first  or  second  treatment 
the  patient  will  have  a  small  unaided  movement.  Ca- 
thartics and  enemata  are,  of  course,  strictly  enjoined. 


INTEENAL  MEDICATION.  89 

Each  day  the  patient  will  report  a  slightly  larger  and 
more  satisfactory  defecation.  When  the  defecation  ap- 
proaches the  normal,  treatments  are  given  only  on  alter- 
nate days.  After  three  or  four  days,  the  interval  is 
lengthened  to  two  days,  and  then  to  three;  and  then  to 
four;  when  the  patient  is  asked  to  report  in  five  or  six 
days.  If  he  reports  satisfactory  evacuations  daily,  he 
is  allowed  to  go  a  week,  and  then,  if  a  similar  report  is 
made,  he  is  discharged  as  cured,  but  asked  to  return  for 
another  treatment  on  the  first  day  on  which  he  does  not 
have  a  normal  stool. 

If  the  case  is  properly  diagnosed  and  instructions  as 
to  a  regular  time  for  daily  evacuations  and  strict  obe- 
dience to  nature's  calls  are  carried  out  by  the  patient, 
as  well  as  the  proper  dietary  being  lived  up  to ;  the  re- 
sults from  this  method  of  treatment  will  be  very  satis- 
factory, as  the  experience  of  several  hundred  practi- 
tioners in  all  parts  of  the  United  States  and  Canada 
will  testify. 

The  only  internal  medication  which  has  been  found  nec- 
essary in  the  author's  experience,  has  been  the  admin- 
istration of  extract  of  nux  vomica  in  one-fourth  to  one- 
half  grain  doses  before  meals  as  a  tonic  to  the  bowel 
muscles.  Pancreatin  in  ten  grain  doses  before  meals 
has  been  found  of  value  in  patients  who  show  symp 
toms  of  intestinal  indigestion.  In  those  cases  where 
starchy  food  is  found  difficult  of  digestion  the  adminis- 
tration of  Takadiastase  in  doses  of  four  to  ten  grains  has 
been  found  of  service.  The  author  has  experienced  great 
satisfaction  from  the  administration  of  white  refined  pe- 
troleum oil,  also  known  as  liquid  albolene.  A  prepara- 


90  OBSTIPATION. 

tion  such  as  the  following  is  a  very  satisfactory  way  of 
administering  it: 

Oil  of  wintergreen  or  peppermint 1  part. 

Refined  white  petroleum  oil 8  parts. 

Directions: — A  teaspoonful  before  each  meal  and  at 
bedtime. 

This  oil  has  no  value  whatever  as  a  cathartic 
and  is  not  acted  upon  by  any  oi  the  digestive  secretions. 
It  passes  through  the  stomach  and  bowel  and  is  expelled 
unchanged.  It  acts  as  a  mechanical  lubricant  to  the 
stool  and  softens  hard  masses  which  have  been  formed 
and  prevents  the  formation  of  others. 

Other  diseases  occurring  coincidently  with  consti- 
pation have  to  be  treated  according  to  their  special  in- 
dications and  needs. 

Obstipation.  Obstipation  as  defined  at  the  beginning 
of  the  chapter  is  a  purely  mechanical  condition,  there 
being  some  pathological  condition  which  narrows,  con- 
stricts, kinks,  or  obstructs  the  bowel  in  such  a  manner  as 
to  offer  more  resistance  than  normal  peristalsis  can  over- 
come. Pressure  from  various  abdominal  organs,  obstruc- 
tion from  intra-abdominal  adhesions,  torsion,  or  angu- 
lation  of  the  bowel  are  conditions  which  can  be  remedied 
only  by  operative  interference  under  general  anesthesia 
and  do  not  come  within  the  scope  of  this  work.  Obstipa- 
tion, however,  which  is  due  to  hypertrophy  of  the  rectal 
valves  or  valves  of  Houston,  fecal  impaction,  or  hypertro- 
phied  sphincters  are  all  amenable  to  office  treatment  un- 
der local  anesthesia. 


THE   RECTAL  VALVES.  91 

The  Rectal  Valves. — While  for  several  years  a  great 
controversy  has  been  raised  as  to  whether  the  rectal 
valves  of  Houston  are  really  valves,  or  simply  constant 
folds  of  mucous  membrane,  nevertheless,  the  fact  that 
hypertrophy  of  these  structures  does  obstruct  and  im- 
pede the  flow  of  the  fecal  current  is  now  generally  admit- 
ted. The  number  of  cases  reported  of  obstipation  which 
have  been  relieved  only  after  section  of  hypertrophied 
rectal  valves,  is  now  so  large  that  the  operation  of  rectal 
valvotomy  has  come  to  be  a  recognized  form  of  treatment. 

Anatomical  studies  of  the  valves  in  situ  and  sections 
of  the  valve  studied  microscopically  have  shown  conclu- 
sively that  they  possess  all  the  elements  of  a  typical 
valve.  They  are  not  simple  folds  of  mucous  membrane, 
but  are  composed  of  first,  mucous  membrane;  second,  a 
fibrous  tissue  layer;  third,  a  circular  muscular  layer; 
fourth,  a  longitudinal  muscular  layer;  and,  fifth,  a  sub- 
serous  layer  consisting  of  areolar  tissue  and  fat  and  con- 
taining arteries,  veins,  nerves,  and  lymphatics.  Under 
certain  conditions  these  rectal  valves  become  thickened 
and  stiffened  by  the  increased  deposition  of  fibrous  tis- 
sue ;  in  fact,  become  almost  leathery  in  consistency  They 
may  or  may  not  encroach  upon  the  lumen  of  the  bowel. 
They  may  not  become  increased  in  thickness  whatever, 
but  may  be  simply  increased  in  area  so  that  they  occupy 
from  one-half  to  three-quarters  or  more  of  the  rectal  lu- 
men. Sometimes  one  valve  may  be  enlarged  and  some- 
times two  or  three.  This  form  of  enlargement  presents 
a  firm  and  unyielding  barrier  to  the  normal  descent  of  the 
feces. 

Patients  -with  so-called  constipation  who  have  run  the 
whole  gamut  of  cathartics,  enemas,  massage,  dietetics, 


92 


RECTAL   VALVOTOMY. 


electricity,  osteopathy  and  Christian  "  Science"  have  not 
been  relieved  until  they  have  had  a  proper  proctologic 
examination  and  the  enlarged  rectal  valves  which  were 
discovered,  operated  upon.  The  author  has  had  repeat- 
edly such  cases  referred  to  him  and  the  operation  of 
valvotomy  has  relieved  a  large  percentage  of  these  cases. 
The  operation  as  performed  on  most  of  these  patients 
was  a  modification  of  that  first  introduced  by  T.  C.  Mar- 
tin,  of  Cleveland.  It  was  a  delicate  operation,  requiring 
considerable  skill  and  special  apparatus ;  the  results  were 
all  that  could  be  wished  for.  The  objections  were,  first, 
that  without  a  general  anesthetic  patients  became  wearied 
and  restless  before  the  operation  was  completed ;  second, 
the  fact  that  a  general  anesthetic  was  required  for  a 
number  of  cases;  third,  that  in  cases  of  unusually  large 
blood  vessels  in  the  valve,  considerable  difficulty  was  ex- 


Fig.  46. 
Author's  Four-Inch  Operating  Proctoscope. 

perienced  with  hemorrhage ;  fourth,  that  the  patient  was 
confined  to  his  house  or  bed  or  the  hospital  for  from 
four  or  five  days  to  a  week. 

The  clamp  of  Gant  and  the  Pennington  clip  greatly 
simplified  the  operation  of  valvotomy ;  so  much  so,  that  it 


AUTHOR'S  OPERATION  FOR  RECTAL  VALVOTOMY.          93 

could  be  done  in  the  physican's  office  without  any  anes- 
thesia and  in  a  very  few  minutes.  The  objection  to  the 
use  of  these  mechanical  contrivances  was  the  fact  of  the 
possibility  of  their  being  carried  up  higher  into  the 
bowel  after  cutting  through  and  also  trauma  of  the  rec- 
tal mucous  membrane  caused  by  the  retention  and  pas- 
sage of  the  irregularly  shaped,  hard,  metallic  bodies. 

Author's  Operation  for  Rectal  Valvotomy.  The  au- 
thor has  devised  an  extremely  simple  technique  which 
has  proved  most  satisfactory  in  his  hands,  and  which  by 
reference  to  the  accompanying  illustrations  can  be  read- 
ily understood.  The  patient  is  put  in  the  knee-shoulder 
position,  and  a  large  operating  size  proctoscope  inserted 


Fig.  47. 
Author's  Rubber  Ligature  Carrier  or  Valvotomy  Needle. 

after  the  sphincter  has  been  prepared  for  it,  either  by 
gradual  dilatation  or  by  immediate  partial  divulsion  fol- 
lowing local  anesthesia  of  the  parts.  The  author's  liga- 
ture carrier  or  valvotomy  needle  depicted  above,  is 
threaded  through  the  eye  at  the  curve  with  a  rubber  liga- 
ture (sizes  5  to  8,  French  scale).  The  ligature  passes 
inside  of  the  curve  of  the  needle  and  should  project  about 
half  an  inch  from  the  point.  The  needle,  which  is  nine 


94  AUTHOR  S  OPERATION  FOR  RECTAL  VALVOTOMY, 

inches  long  and  has  a  handle  bent  at  an  angle  so  as  not 
to  obstruct  the  view,  is  then  passed  up  around  and  hooked 


Fig.  48.       •: 
Author's  Angular  Rectal  Scissors. 

A  very  useful  instrument  for  any  cutting  operation  performed  through 
the  operating  proctoscope. 

through  the  highest  offending  valve  until  the  point  is 
projected  and  the  ligature  can  be  clearly  seen.    This  end 


Fig.  49. 

Technique  of  Author's  Operation  for  Rectal  Valvotomy. 
This   drawing   shows   the  position  of  the  patient   in   the   knee-shoulder 
posture  with  the  author's  valvotomy  needle  threaded  with  a   rubber  liga- 
ture transfixing  the  first  rectal  valve. 


EECTAL  VAL.VOTOMY.  95 

Fig.  50. 
Author's  Rubber  Ligature  Operation  for  Rectal  Valvotomy. 


B. 


Drawn   from  proctoscopic  view. 

A.  A  rubber  ligature  in  place  with  lead  fastener  ready  for  compression. 

B.  Ligature  drawn  taut,  and  lead  fastener  compressed,  showing  amount 

of   constriction. 

C.  Result  three  weeks  after  operation. 


96  RECTAL  VALVOTOMY. 

is  then  grasped  by  means  of  a  long  alligator  forcep  and 
the  ligature  is  pulled  through  until  it  is  outside  the  proc- 
toscope. The  needle  is  then  passed  back  and  around  the 
edge  of  the  valve  and  is  brought  down  also  outside  the 
proctoscope  and  is  then  taken  off  the  ligature.  The  liga- 
ture is  now  in  place  (see  figure  50,  A).  Over  the  ends  is 
slipped  a  lead  fastener  or  large  perforated  shot,  the  liga- 
ture being  put  on  the  extreme  stretch  and  the  shot 
grasped  and  pushed  up  to  the  valve  tightly  by  means  of 
long  compression  forceps  and 'firmly  compressed.  This 
puckers  the  valve  (see  figure  50,  B),  and  constricts  it  in 
such  a  way  that  circulation  is  shut  off  and  the  ligature 
sloughs  through  in  from  two  to  eight  days.  After  the 
ligature  has  cut  through,  the  edges  retract  so  that  a 
large  U-shaped  opening  is  left,  which  gradually  still 
further  retracts.  Fig.  50,  C  shows  the  retraction  in  cases 
in  which  the  rectal  valve  contains  a  considerable  amount 
of  fibro-elastic  tissue. 

The  advantages  of  this  simple  technique  are  as  fol- 
lows: 

First.    It  can  be  done  without  any  anesthetic  whatever. 

Second.  It  can  be  done  quickly;  that  is,  the  whole 
operation  should  not  require  more  than  ten  minutes  for 
three  valves. 

Third.     It  requires  few  instruments  or  appliances. 

Fourth.     The  patient  is  not  confined  to  bed. 

Fifth.  There  is  absolutely  no  hemorrhage ;  no  stitches 
are  required. 

Sixth.  The  rubber  ligature,  being  soft  and  non-irritat- 
ing, does  not  scratch  or  bruise  the  bowel  in  situ  or  during 
its  expulsion,  and  there  is  no  danger  of  its  doing  damage 
if  it  should  by  any  possibility  be  carried  up  higher  into 
the  bowel. 

Seventh.     It  is  simple. 


CHAPTER  V. 


FECAL  IMPACTION. 

This  consists  in  the  formation  and  retention  in  some 
part  of  the  intestinal  canal  of  a  mass  of  hardened  feces. 
In  70  per  cent  of  the  cases  the  fecal  impaction  is  found 
in  the  rectum  and  in  20  per  cent  in  the  sigmoid  flexure. 
The  other  10  per  cent  are  found  in  the  upper  portions  of 
the  intestinal  canal  which  do  not  come  within  the  scope 
of  this  work  and  will  not  be  discussed. 

Causes.  Over-distension  of  the  bowel  caused  by  con- 
stipation may  lead  to  the  formation  of  a  pouch  or  diver- 
ticulum.  This  pouch  becomes  filled  with  fecal  matter  and 
on  account  of  the  atonic  condition  of  its  muscular  fibres, 
is  unable  to  completely  empty  itself  during  defecation. 
This  leads  to  absorption  of  the  fluid  constituents  of  the 
stool  and  leaves  behind  a  hardened  fecal  mass  whose  con- 
sistency ranges  from  that  of  stiff  clay  to  calcareous,  as 
in  enteroliths,  or  fecal  concretions,  which  are  composed 
largely  of  lime  salts.  Bits  of  bone,  fruit  and  vegetable 
seeds,  fruit  stones,  indigestible  vegetable  fibre,  concre- 
tions of  bismuth,  salol,  magnesia,  or  other  insoluble 
drugs,  taken  internally,  may,  become  the  nidus  of  a  fecal 
concretion  which  in  turn  is  frequently  the  underlying 
cause  of  fecal  impaction.  Gall  stones  may  also  be  respon- 
sible for  their  formation. 

97 


98  SYMPTOMS. 

Symptoms.  The  symptoms  of  fecal  impaction  are 
those  of  obstipation,  coming  on  rather  suddenly  with 
more  or  less  intestinal  distension,  accompanied  with  pain 
in  the  rectum,  and  extending  to  the  left  inguinal  re- 
gion, and  frequently  shooting  down  the  left  leg.  The 
patient  will  complain  of  a  frequent  desire  for  stool,  but 
inabilty  to  accomplish  the  same  on  account  of  a  sense  of 
weight  and  blocking  up  of  the  rectum.  If  the  impaction 
is  low  he  may  feel  it  impinging  on  the  anus  following  the 
effort  at  expulsion.  The  pressure  on,  and  irritation  of 
the  mucous  membrane,  caused  by  the  presence  of  this 
hard  foreign  body,  starts  up  a  hypersecretion  of  mucus 
and  causes  ulceration  of  the  bowel.  This  causes  in  many 
instances  a  diarrhoea  characterized  by  frequent,  small, 
irritating,  watery,  and  mucous  stools  which  often  contain 
blood  and  frequently  pus. 

Cases  have  been  reported  in  which  the  impaction  has 
become  channelled,  where  after  a  period  of  almost  com- 
plete obstruction,  the  patients  have  had  stools  apparently 
normal.  In  cases  where  the  impaction  occurs  in  a  pouch, 
or  diverticulum,  this  may  also  occur.  In  these  cases,  how- 
ever, the  feeling  of  weight,  heaviness,  and  discomfort  in 
the  sigmoid  or  rectum  is  still  present  and  there  is  more 
or  less  tenesmus  and  an  unsatisfied  feeling  after  stool. 

In  women,  pressure  from  a  large  impaction  on  the 
uterus,  or  ovaries,  may  cause  anterior  displacement  and 
symptoms  of  uterine  irritation.  Through  direct  pressure 
and  reflexly,  the  bladder  becomes  irritable  and  frequent 
micturition  results.  Patients  suffering  from  impaction 
usually  present  in  addition  to  the  foregoing,  symptoms  of 
auto-intoxication,  such  as  dizziness,  headache,  coated 
tongue,  foul  breath,  indigestion,  with  or  without  vomiting, 


DIAGNOSIS  AND  TREATMENT.  99 

abdominal  distension,  lack  of  ambition,  and  general  ma- 
laise. 

Diagnosis.  The  diagnosis  is  not  difficult.  By  recto- 
abdominal  palpation,  the  round,  or  often  nodular  mass, 
can  be  made  out  in  the  lower  left  inguinal  region,  or  in 
the  rectum  itself.  To  the  examining  finger  in  the  rectum, 
it  may  be  hard  and  nodular,  or  owing  to  its  being  in  a 
pouch  or  diverticulum  and  almost  completely  surrounded 
by  mucous  membrane,  it  may  give  an  impression  of  being 
an  extra-rectal  pelvic  tumor. 

On  direct  examination  with  the  proctoscope  with  the 
patient  in  the  knee-shoulder  position,  and  the  rectum 
inflated,  the  impaction  can  be  easily  made  out.  It  is  im- 
portant in  using  the  proctoscope  to  so  carefully  manipu- 
late the  instrument  so  as  to  see  behind  each  rectal  valve, 
as  not  infrequently  the  pouching  occurs  in  any  of  these 
locations  and  the  contained  impaction,  or  concretion,  is 
almost  completely  hidden  from  sight.  If  palpation  dis- 
closes a  mass  in  the  sigrnoid  flexure  examination  with  the 
sigmoidoscope  may  be  resorted  to  in  order  to  demon- 
strate the  impaction  or  concretion  to  the  eye.  It  is 
important  to  determine  either  by  ocular  inspection,  or 
examination  with  a  sound,  whether  we  are  dealing  with 
an  impaction  of  clay-like  consistency,  or  a  hard  concre- 
tion, as  the  treatment  of  the  two  is  necessarily  somewhat 
different. 

Treatment.  The  treatment  of  this  condition  consists 
of  the  prompt  removal  of  the  impacted  mass.  Situated  in 
the  rectum  and  reached  by  the  finger  it  may  be  easily 
broken  up  without  the  use  of  any  instrument,  providing  it 
is  of  recent  origin  and  its  consistency  not  firmer  than 
stiff  clay.  When  it  is  situated  beyond  the  reach  of  the 


100  TREATMENT. 

finger  or  if  of  too  firm  a  consistency  to  be  easily  manipu- 
lated, the  injection  of  8  or  10  fluid  ounces  of  liquid 
albolene,  olive,  or  cotton  seed  oil  through  a  rectal  tube 
large  enough  to  reach  well  into  the  sigmoid,  and  this 
allowed  to  remain  for  12  hours;  will  often  so  soften  and 
separate  the  mass  that  it  can  be  passed  without  any  dif- 
ficulty. In  many  cases  this  will  bring  the  impaction  down 
so  low  into  the  rectum  that  it  can  be  broken  up  with  the 
finger  or  a  dull  spoon  curette  used  through  the  procto- 
scope with  the  patient  in  either  the  lateral  or  lithotomy 
position. 

The  most  reliable  method  is,  however,  the  injection  of 
peroxide  of  hydrogen  in  solutions  varying  in  strength 
from  10  to  25  per  cent.  With  the  patient  in  the  lateral 
position,  2  to  4  oz.  of  peroxide  solution  is  injected  through 
a  soft  rubber  rectal  tube  inserted  up  to  the  impaction. 
The  tube  is  allowed  to  remain  in  place  and  at  the  end  of 
5  minutes  the  rectum  irrigated;  when  it  will  be  found 
that  the  impacted  mass  has  been  disintegrated  through 
the  mechanical  action  of  the  liberated  gas  and  is  easily 
washed  out.  Several  injections  of  the  peroxide  solution 
may  be  necessary  but  if  persisted  in,  it  may  be  relied 
upon  to  do  the  work.  When  the  mass  is  of  long  standing 
and  so  hard  that  it  takes  on  the  characteristics  of  a  true 
concretion,  it  may  become  necessary  to  dilate  the  sphinc- 
ters under  local  anesthesia  and  to  break  up  the  mass  with 
a  short  jawed  lithotribe  passed  through  an  operating  size 
proctoscope.  When  the  concretion  is  larger  than  li/> 
inches  in  its  widest  circumference  it  is  safest  and  best  to 
administer  nitrous  oxide,  divulse  the  sphincters,  crush 
the  concretion,  and  remove  the  fecal  mass  with  forceps. 


AFTER  TREATMENT.  101 

After  the  impaction  has  been  removed,  the  patient 
should  be  put  on  a  liquid,  absorbable  diet  for  two  or  three 
days.  Liquid  albolene  should  be  administered  in  doses  of 
one  or  two  teaspoonsful  four  times  daily  and  regular 
daily  defecations  encouraged.  The  atonic  condition  of  the 
rectum  should  be  overcome  by  the  use  of  the  author's 
pneumatic  massage  bag  as  outlined  in  the  chapter  on  the 
treatment  of  chronic  constipation. 


CHAPTER  VI. 


PRURITUS  ANI. 

Pruritus  Ani  is  probably  the  most  annoying  symptom 
which  accompanies  any  disease  of  thtf  rectum.  It  is  be- 
cause of  the  intense  suffering  and  discomfort  which  it 
causes  when  present,  that  it  has  been  given  the  promi- 
nence and  importance  that  is  accorded  it  of  treating  it  as 
if  it  were  a  disease  by  itself. 

Pruritus  Ani  which  is  an  accompanying  symptom  of  so 
many  different  diseases,  in  reality  should  not  be  con- 
sidered alone  as  a  disease  any  more  than  rectal  pain  or 
rectal  hemorrhage.  Like  constipation,  however,  it  i  s  such 
an  important  symptom,  and  often  the  only  apparent 
symptom,  of  some  diseased  condition,  that  it  has  been 
thought  wise  to  emphasize  it  in  this  chapter,  and  lo  speak 
of  some  of  the  conditions  which  most  frequently  cause  it. 

Pruritus  Ani  may  be  caused  by  or  accompany  every 
known  anal  or  rectal  disease,  as  well  as  many  diseases 
affecting  other  organs  or  general  in  character.  In  other 
words,  it  may  be  caused  by : 

1.  Any  disease  of  the  rectum  or  anus. 

2.  Any  skin  disease  affecting  the  anal  region. 

3.  As  a  reflex  from  diseases  of  the  bladder,  prostate 
gland,  uterus,  ovaries,  vagina, — in  fact  any  part  of  man 
or  woman's  uro-genital  apparatus. 

102 


-,  ETIOLOGY.  103 

4.  General  or  constitutional  diseases. 

5.  Dietary  disturbances. 

6.  Parasites. 

7.  Irritation  from  clothing,  detergents,  or  moisture. 
The  discussion  of  the  various  anal  and  rectal  diseases 

which  present  Pruritus  Ani  as  a  symptom  will  be  taken 
up  in  the  respective  chapters  devoted  to  those  diseases. 
The  skin  diseases  most  commonly  affecting  the  anal  re- 
gion are  marginal  eczema,  herpes,  erythema,  scabies,  and 
folliculitis. 

Stone  in  the  bladder  is  not  infrequently  accompanied 
by  an  itching  of  the  anus  and  perineum.  Chronic  pros- 
tatitis,  vesiculitis,  urethritis,  phimosis,  and  cystitis  may 
also  be  accompanied  by  itching  of  this  region.  Any 
disease  of  the  uterus  or  adnexa  may  cause  itching  in  the 
region  of  the  anus  and  many  times  the  symptom  of  pruri- 
tus is  caused  by  some  irritating  discharge  from  the 
vagina. 

Pediculi,  thread  worms  (oxyuris  vermicularis),  itch- 
mite  (acarus  scabiei),  ringworm  (trichophyton),  are  the 
most  common  parasites  manifesting  their  presence  in  the 
anal  region  by  itching. 

Among  the  diseases  of  a  more  general  character  which 
are  frequently  found  to  be  the  cause  of  itching  at  the  anus 
are  diabetes,  malaria,  uric  acidosis,  nephritis,  tuberculo- 
sis, syphilis,  and  hysteria.  Many  patients  suffer  from  an 
attack  of  Pruritus  Ani  after  partaking  of  alcoholic  stimu- 
lants in  excess.  In  others,  the  excessive  use  of  tobacco, 
coffee,  tea  and  spices  also  conduce  to  the  production  of 
this  symptom.  Some  patients  are  subject  to  attacks  of 
Pruritus  Ani  only  during  the  strawberry  season,  while 
others  have  an  attack  every  time  they  partake  of  sea 


104  ETIOLOGY. 

foods,  particularly  of  the  shell  fish  family.  Some  patients 
possess  an  idiosyncrasy  toward  some  one  food  or  class  of 
foods,  and  it  is  the  indulgence  in  this  class  only  which 
brings  on  an  attack  of  Pruritus  Ani  in  this  particular 
individual. 

In  many  cases  the  itching  is  caused  by  mechanical 
irritation  of  the  skin  surrounding  the  anus  or  by  the  use 
of  coarse  or  harsh  material  in  cleansing  the  anus  after 
defecation.  Some  writers  claim,- that  the  printer's  ink 
on  newspapers  acts  as  a  special  irritant  to  the  anus.  The 
wearing  of  underwear  colored  with  dyes  which  are  not 
fast,  as  well  as  the  pressure  of  clothing  which  fits  too 
snugly  in  the  perineal  region;  the  irritation  caused  by 
excessive  sweating,  particularly  in  stout  individuals ;  and 
those  who  are  forced  to  work  in  a  high  temperature,  such 
as  engineers,  stokers,  moulders,  and  gas  workers;  are 
often  responsible  for  the  production  of  Pruritus  Ani. 
Personal  uncleanliness  in  this  region  is  too  often  found  to 
be  the  cause  of  pruritus,  as  in  other  parts  of  the  body. 

There  has  been  a  condition  described  by  some  writers  as 
idiopathic  Pruritus  Ani,  because  of  the  presence  of  itch- 
ing of  the  anus  alone  as  the  symptom,  and  the  discovery 
of  no  other  apparent  cause  for  its  existence.  I  do  not  be- 
lieve that  there  is  such  a  thing  as  idiopathic  Pruritus  Ani. 
I  have  seen  cases  in  my  practice  where  after  the  most 
painstaking  and  thorough  search  no  cause  could  be  found 
for  the  itching,  yet  I  believe  there  was  a  local  cause,  only 
it  was  not  discovered.  The  fact  that  some  of  these  cases 
are  cured  empirically  by  stretching  of  the  sphincter 
muscles  would  seem  to  indicate  that  there  might  be  some 
local  condition  irritating  the  nerve  endings  which  was 
mechanically  relieved  by  the  stretching  process. 


APPEARANCE    OF    THE   ANUS   IN    PRURITUS   ANI. 


105 


The  appearance  of  the  anus  and  perineum  in  the  pa- 
tient suffering  from  Pruritus  Ani  is  quite  characteristic — 
the  skin  around  the  anus  being  thrown  into  numerous, 
deep  folds  radiating  from  the  anal  orifice  (Fig.  51).  In 
those  cases  accompanied  by  more  or  less  moisture  the  skin 
is  white,  soggy,  and  more  or  less  macerated,  with  here  and 


Fig.   51. 
Pruritus  Ani. 

This  drawing  made  from  a  photograph  of  one  of  the  author's  cases, 
shows  the  characteristic  cracking  around  the  margin  of  the  anus  and 
at  the  posterior  commissure,  and  also  shows  the  area  of  irritation  of 
the  opposing  surfaces  of  the  buttocks. 

there,  small  raw  areas  where  the  skin  has  been  denuded 
of  epithelium  by  scratching.  In  other  cases  of  not  so  long 
standing,  we  find  the  skin  around  the  anus  normal  in  color 
but  dry  with  a  tendency  to  scale.  The  cutaneous  folds 
are  not  so  deep,  but  in  the  sulci  are  found  small  cracks 


106 


EXTENT    OF    IRRITATION    AND    EXCORIATION. 


in  the  skin  and  extending  up  into  the  mucous  membrane. 
In  many  cases  particularly  in  stout  individuals,  a  long 
raw  fissure^or  crack  may  be  found  extending  along  the 
median  raphe  anteriorally  to  the  scrotum  or  posteriorly 
into  the  median  perineal  crease  for  a  distance  of  from  one 


Fig.  52. 

External  Integumentary  Hemorrhoids  Accompanied  by  Pruritus  Ani. 
This   photograph    of   one   of   the   author's   cases,    shows    the   extent   to 
which   cutaneous  irritation  may  go ;   in   this  case   extending  up   over  the 
sacrum  and  down  nearly  half  way  to  the  knees. 

to  four  or  five  inches.  The  skin  surrounding  the  anus 
and  these  various  cracks  may  be  reddened  and  excoriated 
for  a  great  distance  from  the  lesion.  It  may  extend  some 
distance  up  onto  the  abdomen  or  down  the  thighs  (Fig. 


CHARACTERISTICS    OF    THE    ITCHING.  107 

52)  and  legs  to  the  knees  In  cases  of  long  standing  the 
skin  surrounding  the  anus  loses  its  elasticity  and  becomes 
hard,  thick,  and  leathery.  This  condition  is  in  reality  due 
more  to  the  scratching  and  rubbing  by  the  patient  in  his 
futile  efforts  to  relieve  the  condition,  than  to  any  patho- 
logical condition  brought  about  by  the  itching  itself. 

Pruritus  Ani  may  mean  anything  from  a  slight  feeling 
of  uneasiness  or  irritation  in  the  anal  region  to  an  intense 
burning,  almost  crazing,  itching  characteristic  of  the  most 
aggravated  types.  There  are  several  things  character- 
istic about  this  itching: 

1.  It  is  usually  more  intense  at  night. 

2.  It  tends  to  become  progressively  worse. 

3.  It  is  not  relieved  by  scratching. 

4.  In  spite  of  the  fact  that  the  sufferer  soon  realizes 
that  the  scratching  or  rubbing  only  aggravates  the  con- 
dition, he  persistently  and  constantly  continues  to  scratch. 

While  every  disease  affecting  the  rectum  or  anus  may 
be  responsible  for  the  production  of  Pruritus  Ani,  those 
that  most  commonly  cause  it  are  fissure  of  the  anus,  ul- 
cer, particularly  of  the  anal  canal;  fistula-in-ano  either 
complete  or  blind,  hypertrophied  papillae  and  proctitis. 
The  reader  is  referred  to  the  respective  chapters  describ- 
ing these  conditions  with  their  diagnosis  and  treatment. 
Every  case  of  Pruritus  Ani  demands  the  most  careful  in- 
vestigation, into  the  patient's  habits,  occupation,  and 
mode  of  living ;  as  well  as  the  most  thorough  examination 
of  the  anus,  rectum,  sigmoid,  and  adjoining  organs. 

Unfortunately  in  some  few  cases  where  pathological 
conditions  have  been  found  in  the  anus  or  rectum,  which 
were  thought  to  be  the  cause  of  Pruritus  Ani,  their  re- 
moval has  not  relieved  the  itching.  In  fact,  on  account  of 


108  NON-SURGICAL  TREATMENT. 

the  healing  by  granulation  and  the  resultant  scar  tissue, 
some  cases  have  been  reported  in  which  the  itching  has 
been  aggravated.  It  is  important,  therefore,  to  be  very 
guarded  in  the  prognosis  and  not  promise  a  cure. 

The  treatment  of  Pruritus  Ani  is  of  course  the  treat- 
ment of  the  disease,  whether  local  or  general,  which 
causes  it;  and  the  reader  must  use  his  general  medical 
knowledge  in  the  treatment  of  diseases  of  a  constitutional 
nature  and  in  treating  those  of  the  general  diseases  men- 
tioned above,  as  that  does  not  come  within  the  scope  of 
this  work.  The  treatment  of  the  symptom  itching,  must 
be  simply  palliative,  while  the  treatment  of  the  condition 
which  is  responsible  for  the  itching  is  being  carried  out. 
If  due  to  any  of  the  rectal  or  anal  diseases  mentioned 
herein,  follow  out  the  treatment  as  laid  down  in  the 
various  chapters.  If  due  to  any  skin  disease  of  the  part 
such  as  marginal  eczema,  consult  any  good  work  on  der- 
matology and  treat  it  as  you  would  any  other  skin  disease 
in  any  part  of  the  body.  The  author  has  found  the  fol- 
lowing ointment  a  most  successful  one  in  these  cases: 

V 

Pv.  Calamine 2  drachms. 

Zinc  Oxide 1  drachm.. 

Calomel 15  grains. 

Ac.  Phenic 20  drops. 

Lanolin 1  ounce. 

M.  Ft.  Unguentum. 

This  is  applied  freely  to  the  parts  after  cleansing 
and  thoroughly  drying,  after  each  bowel  movement  and 
at  night.  In  some  cases  where  there  is  considerable 
moisture  the  following  powder  may  be  used  instead  of 
the  ointment : 


NON-SURGICAL  TREATMENT.  109 

V 

Chloretone 30  grains. 

Pv.  Calamine   2  drachms. 

Zinc  Oxide 1  drachm. 

Calomel 30  grains. 

M.  &  Ft.  dusting  powder. 

This  is  applied  in  the  same  manner  as  the  ointment. 

Herpes  and  erythema  of  the  skin  surrounding  the 
anus  may  be  relieved  by  the  application  of  the  Compound 
Stearate  of  Zinc  with  Balsam  Peru.  The  parts  must  be 
protected  and  the  surfaces  kept  from  rubbing  against 
each  other  by  absorbent  cotton.  Scabies  is  best  treated 
by  the  ordinary  sulphur  ointment  of  the  pharmacopoeia. 
Where  inflammation  of  the  hair  follicles  exists  with  the 
formation  of  pustules  they  must  be  opened,  washed  with 
a  25  per  cent  solution  of  peroxide  of  hydrogen  and  then 
dressed  with  a  compress  of  any  of  the  standard  antiseptic 
solutions,  boracic  acid  being  used  by  the  author.  Where 
the  pediculi  pubis  is  suspected,  liberal  applications  of  blue 
ointment  or  fluid  extract  of  larkspur  should  be  used.  In 
ring  worm,  the  trichophyton  may  be  reached  by  sulphur 
ointment.  Where  thread  worms  are  present,  lime  water 
enemata  will  very  quickly  relieve.  It  should  be  injected 
twice  daily  using  from  4  ounces  to  i/^-pint  at  each  sitting 
and  capsules  containing  one-half  grain  calcium  sulphide, 
given  three  times  daily  before  meals. 

In  cases  where  excessive  indulgence  in  smoking,  alco- 
holic stimulants,  and  articles  of  diet  which  produce  or 
aggravate  itching  is  responsible ;  it  is  obvious  that  these 
indulgences  must  be  interdicted.  Where  the  occupation 
or  habits-  are  at  fault,  changes  are  necessary  in  order  to 
bring  about  the  best  results.  The  remedies  or  combina- 


HO  NON-SURGICAL  TREATMENT. 

tion  of  remedies  which  are  recommended  for  Pruritus 
Ani  are  many.  Blackwash  is  recommended  by  many  au- 
thorities as  an  old  reliable  remedy.  Tuttle  considers  car- 
bolic acid  in  ointment  or  solution  from  five  to  twenty 
per  cent  as  the  most  generally  applicable  of  all  drugs  for 
the  relief  of  Pruritus  Ani.  He  recommends  this  pre- 
scription : 

Ac.  carbolici 2  drachms. 

Ac.  salicylici 1  drachm. 

Glycerine  1  drachm. 

M.  sec.  art. 

Sig. — Apply  to  the  parts  with  camels'  hair  brush  or 
cotton  swab  softened  in  hot  water. 

Cripps  recommends : 

Acidi   Carbolici   V2  drachm. 

Unguentum  hydra rg.  nitratis 2  drachms. 

Ung.  Petrolii 1  ounce. 

Another  ointment  of  which  he  speaks  very  highly  of  is: 

Extracti  conii 1  drachm. 

Olei  ricini 1  drachm. 

Ung.  lanolini,  ad 1  ounce. 

Where  ointments  do  not  agree  Kelsey  recommends  this 
lotion : 

Sodii  biboratis 2  drachms. 

Morphiae  hydrochlor 16  grains. 

Acidi  hydrocyanic  Dil y2  ounce. 

Glycerine   2  ounces. 

Aquae,   ad __  8  ounces. 

Cripps  also  recommends  a  lotion  containing  2  grains  of 
bichloride  of  mercury  to  the  ounce  of  lime  water  as  an 


NON-SURGICAL  TREATMENT.  Ill 

application,   after   thoroughly  washing  the  parts   with 
soap  and  water. 

Gant  recommends  as  a  hard  ointment  the  following : 

9 

Carbolic  acid 20  grains. 

Menthol    10  grains. 

Camphor   10  grains. 

Suet 1  ounce. 

M.  Sig :  Apply  freely  2  or  3  times  daily  after  cleansing 
the  parts.  In  the  preparation  of  the  above  he  advises  to 
melt  the  suet  and  when  partly  cooled  to  add  the  other 
ingredients.  He  especially  cautions  against  adding  oil 
as  the  ointment  should  be  quite  hard,  the  object  being  to 
form  a  coating  over  the  parts  which  will  not  be  penetrated 
by  the  secretions.  Citrine  ointment  (unguentum  hydrar- 
gyri  nitratis)  is  highly  recommended  by  Gant  in  cases 
where  it  is  necessary  to  restore  the  circulation  and  the 
indurated  skin  to  its  normal  color  and  suppleness. 
Through  the  suggestion  of  Dr.  L.  H.  Adler,  Jr.,  Gant  uses 
it  in  the  following  manner:  After  the  parts  have  been 
bathed  in  warm  water  the  citrine  ointment  (which  may 
have  to  be  weakened  in  some  cases  by  the  addition  of 
lard)  should  be  spread  on  several  thicknesses  of  gauze, 
applied, covered  with  oiled  silk, and  held  in  place  by  a  snug 
T-bandage.  This  ointment  should  be  kept  on  constantly, 
or  in  some  cases  it  may  be  found  necessary  to  alternate  it 
with  an  ointment  containing  20  grains  of  calomel  to  an 
ounce  of  petrolatum. 

In  the  author's  experience  for  the  mere  relief  of  itch- 
ing, compresses  or  enemas  of  water  as  hot  as  can  be  borne 
has  given  the  greatest  relief  in  the  greatest  number  of 
cases.  Sometimes  cold  acts  better  than  hot.  An  ointment 


112  MECHANO-THERAPY. 

containing  twenty-five  per  cent  of  chloretone  in  white 
cold  cream  has  proven  very  efficacious  in  the  author's 
hands  for  the  same  purpose. 

In  cases  presenting  a  fissured  condition  of  the  anus 
skin  and  mucous  membrane,  the  application  of  100  per 
cent  solution  of  nitrate  of  silver  will  cause  a  desquama- 
tion  of  the  entire  surface  within  24  hours.  Then  a  5  per 
cent  solution  of  ichthyol  in  flexible  collodion  is  applied  on 
alternate  days.  The  use  of  a  mechanical  vibrator,  using 
a  cone-shaped  vibratode  for  five  minutes  at  a  time,  using 
from  5000  to  7000  strokes  a  minute  and  inserted  as  far 
as  can  be  borne  by  the  patient,  will  often  afford  much  re- 
lief. Firm  pressure  by  means  of  a  hard  rubber  rectal 
plug  affords  relief  to  some  individuals  where  all  other 
measures  have  failed.  It  must  be  borne  in  mind  that 
while  any  of  the  remedies  mentioned  herein  are  being 
used  to  relieve  the  itching,  that  they  are  but  palliative, 
and  the  permanent  relief  of  the  itching  comes  only  after 
the  diagnosis  and  cure  of  the  condition  which  causes  it. 
This  must  be  diagnosed  and  studied  for  treatment  and  if 
the  condition  is  not  amenable  to  nonsurgical  treatment  or 
operative  treatment  under  local  anesthesia  it  is  more  like- 
ly a  case  for  the  proctologist  than  for  the  general  prac- 
tioner,  and  his  aid  should  be  called  in. 

If  the  itching  is  caused  by  the  discharge  from  rectal 
cancer  or  from  the  small,  shallow  ulcerations  of  the  mu- 
cous membrane  between  the  sphincters,  which  Wallis  of 
London  claims  is  the  cause  of  90  per  cent  of  all  cases 
of  true  Pruritus  Ani— then  the  indicated  surgical  pro- 
cedures should  be  carried  out,  whereupon  the  itching  will 
be  relieved.  The  writer  would  suggest  that  one  should 
carefully  read  over  the  chapters  on  constipation,  anal 


SURGICAL  TREATMENT. 


113 


fissure  and  ulcer,  fistula,  hemorrhoids,  and  hypertrophied 
papillae,  as  well  as  the  chapter  on  the  examination  of 
the  patient  before  attempting  to  treat  a  case  presenting 
Pruritus  Ani  as  a  symptom. 

In  many  cases,  the  local  condition  seems  to  imperatively 
demand  surgical  treatment,  and  in  many  of  these  patients 
prompt  relief  is  experienced  after  the  indicated  opera- 
tion. The  author  describes  below  those  which  he  can 
safely  recommend. 


Fig.  53. 
A  Simple  and  Satisfactory  Rectal  Dressing. 

Consisting  of  a  gauze  covered  cotton  pad  and  two  strips  of  adhesive 
plaster. 


114  HAMILTON'S  OPERATION. 

Surgical  Measures.  In  those  cases  of  Pruritus  Ani 
in  which  the  skin  surrounding  the  anal  orifice  has  been 
hypertrophied  and  thrown  into  heavy  folds  and  the  sulci 
between  these  folds  fissured,  irritated,  and  giving  forth 
an  irritating  discharge ;  a  simple  surgical  procedure  will 
often  give  relief.  E.  A.  Hamilton,  of  Columbus,  0.,  ad- 
vises the  removal  of  these  hypertrophied  skin  folds  under 
local  anesthesia,  and  reports  very  good  results  from  his 
method. 

Where  there  are  only  two  or  three  folds  involved,  they 
can  all  be  removed  at  one  sitting.  Otherwise,  the  opera- 
tion may  have  to  be  done  at  different  sittings,  with  inter- 
vals between  long  enough  to  allow  of  complete  healing  of 
the  ones  already  operated  upon. 

After  cleansing,  sterilizing  and  shaving  the  parts,  the 
patient  is  placed  either  in  the  lithotomy  or  lateral 
position.  Each  fold  to  be  removed  is  injected  from 
its  outermost  point  with  %  to  1  per  cent  solution 
of  eucain  lactate.  After  allowing  a  couple  of  min- 


Fig.  54. 
Sharp  Pointed  Scissors  Curved  on  the  Flat. 

utes  for  the  anesthetic  to  take  effect,  the  fold  is  re- 
moved by  grasping  its  apex  with  a  pair  of  forceps 
and  cutting  it  out  at  its  base  with  a  sharp  scissors 
curved  upon  the  flat  or  by  elliptical  incisions  with  the  seal- 


REMOVAL   OF   POSTERIOR   TRIANGULAR    FLAP.  115 

pel.  The  other  fold  or  folds  are  treated  in  like  manner 
and  the  wound  surfaces  allowed  to  heal  by  granulation. 
The  bowels  are  kept  confined  for  three  days,  and  then 
moved  by  the  administration  of  a  heaping  teaspoonful  of 
compound  licorice  powder  on  the  evening  of  the  third 
day,  followed  the  next  morning  by  an  oil  enema  of  six 
or  eight  ounces.  Applications  of  bovinine  three  or  four 
times  daily  to  the  wound  surfaces  will  greatly  hasten 
healing.  After  two  or  three  weeks  another  two  or  three 
folds,  preferably  those  situated  opposite  to  those  pre- 
viously removed,  can  be  dealt  with  in  a  like  manner  and 
the  same  technique  carried  out  until  all  the  redundant 
tissue  has  been  removed. 

Where  the  pruritus  is  most  persistent  at  the  posterior 
commissure  of  the  anus,  and  examination  at  that  point 
shows  either  nothing  but  a  thickened  and  irritated  area 
extending  a  short  way  into  the  anal  canal,  or  shallow 
excoriations  at  the  anal  margin  which  are  neither  fis- 
sures or  ulcerations ;  the  removal  of  a  triangular  flap  of 
skin  at  this  point  is  often  followed  by  relief  of  the  symp- 
toms. 

The  technique  is  as  follows:  After  cleansing,  steriliz- 
ing and  shaving  the  parts,  a  point  three-quarters  of  an 
inch  behind  the  posterior  commissure  is  selected  and  one- 
half  of  one  per  cent  solution  of  eucain  lactate  injected  so 
as  to  include  a  triangle  whose  apex  is  the  point  of  injec- 
tion and  whose  base  extends  from  one-quarter  to  one- 
half  inch  to  either  side  of  the  posterior  anal  commissure. 
The  infiltration  of  the  anesthetic  solution  should  extend 
up  into  the  anal  canal  far  enough  to  include  any  exco- 
riated or  irritated  areas.  A  triangular  flap  of  skin  is  dis- 
sected up  by  means  of  the  sharp  scalpel  or  sharp  pointed 


116  BALL'S  OPERATION. 

scissors  curved  upon  the  flat — starting  at  the  point  of  in- 
jection and  extending  to  the  posterior  margin  of  the  anus. 
The  incisions  then  should  be  brought  towards  each  other 
so  as  to  meet  at  a  point  one-quarter  of  an  inch  above  the 
diseased  area  in  the  anal  canal.  The  latter  part  of  the 
operation  makes  a  short,  broad  triangle  whose  base  is  the 
same  as  the  base  of  a  longer  one  on  the  skin  surface.  This 
leaves  a  denuded  area  kite-shaped  as  it  were.  The  skin 
is  brought  together  by  three  or  four  No.  1  or  2  chromi- 
cized  cat  gut  sutures,  boro-chloretone  powder  applied, 
and  the  wound  protected  with  a  gauze  pad  held  in  place  by 
adhesive  strips.  (Fig.  53.)  The  care  of  the  bowels  is  the 
same  as  that  outlined  above,  and  the  after  treatment  con- 
sists of  daily  cleansing  of  the  parts  and  re-application  of 
boro-chloretone  or  compound  stearate  of  zinc  powder. 
Healing  will  take  place  in  from  four  to  seven  days  and 
the  relief  experienced  by  the  patient  after  this  procedure 
in  selected  cases  is  very  satisfactory  indeed. 

Ball's  Operation. — Perhaps  the  most  successful  sur- 
gical measure  for  the  relief  of  persistent  Pruritus  Am', 
which  is  available  for  employment  under  local  anesthesia, 
is  the  ingenious  operation  devised  by  Sir  Charles  Ball, 
of  Dublin. 

As  described  in  Ball's  work  on  "The  Rectum",  its  em- 
ployment is  advocated  under  general  anesthesia.  The 
author,  however,  has  been  able  to  perform  the  operation 
with  brilliant  results  by  the  employment  of  local  anesthe- 
sia. The  object  of  the  operation  is  for  the  purpose  of  di- 
viding all  the  sensory  nerve  twigs  supplying  the  skin  of 
the  anus,  anal  canal  and  circum-anal  region;  which  arise 
from  branches  of  the  third  and  fourth  sacral  nerves,  come 


AUTHOR'S  TECHNIQUE  FOB  BALL'S  OPERATION.         117 

down  to  the  levator  ani  muscle,  and  reach  the  skin  by 
perforating  the  external  sphincter. 

The  technique  as  employed  by  the  author  is  as  follows : 
The  patient  is  given  a  hypodermic  injection  of  one- 
quarter  grain  of  morphine  and  1-150  grain  of  atropine 
and  is  placed  in  the  left  lateral  or  Sims'  position,  and  the 
area  surrounding  the  anus  cleansed,  shaved  and  sterilized. 
An  ounce  of  one-eighth  of  one  per  cent  solution  of  beta 
eucain  lactate  should  be  prepared  and  in  readiness.  Ten 
or  twelve  sharp  pointed  curved  needles  each  threaded 
with  No.  2  chromicized  cat  gut;  a  couple  of  sharp,. small 
bladed  scalpels;  sharp  pointed  scissors  curved  on  the 
flat;  two  pairs  of  T-forceps,  and  two  or  three  hemosta- 


Fig.  55. 
T — Forceps. 


tics,  and  the  syringe  for  injecting  the  solution  are  all  the 
instruments  required.  Selecting  the  point  about  one-half 
inch  behind  the  posterior  extremity  of  the  lines  of  in- 
cision in  Fig.  56,  the  skin  and  subcutaneous  tissue  is 


118        AUTHOR'S  TECHNIQUE  FOR  BALL'S  OPERATION. 

infiltrated.  From  this  point  the  area  included  inside 
the  lines  in  Fig.  56  and  for  one-half  inch  beyond,  is  dis- 
tended until  complete  anesthesia  is  secured  up  to  the  ano- 
rectal  juncture.  The  presence  or  absence  of  skin  sensi- 
bility to  pain  should  be  tested  before  starting  to  operate. 


Fig.  56. 
Ball's  Operation  for  Pruritis  Ani. 

Elliptical  lines  of  incision  on  either  side  of  the  anus. 
From  a  photograph  of  one  of  the  author's  cases. 

The  incisions,  as  outlined  in  the  above  illustration,  are 
then  made  with  a  sharp  knife  down  through  the  skin  to 
the  subcutaneous  tissue.  The  area  included  between  the 
lines  of  incision  should  be  of  elliptical  shape,  and  about 
twice  as  long  in  the  antero-posterior  direction  as  it  is 
broad  in  the  lateral,  with  the  anal  canal  as  its  center. 
With  the  patient  in  the  left  lateral  position,  the  incision 


AUTHOR  S  TECHNIQUE  FOE  BALL  S  OPERATION. 


119 


on  the  left  side  is  made  first,  the  inner  flap  of  skin  is 
grasped  with  T-forceps,  and  by  rapid  and  careful  dissec- 
tion with  the  scalpel  is  raised  from  the  surface  of  the 
external  sphincter  muscle  and  freed  up  to  the  ano-rectal 
juncture.  The  anterior  and  posterior  pedicles  between 
the  ends  of  the  incisions  are  freed  from  the  subcutaneous 
tissues  as  well.  In  other  words,  all  connection  between 
the  funnel-shaped  cutaneous  and  muco-cutaneous  cover- 


Fig.  57. 

Ball's  Operation  for  Inveterate  Pruritus  Ani. 

Method  of  dissecting  the  flaps  and  of  dividing  the  terminal  cutaneous 
nerve  twigs,  which,  for  the  purpose  of  clearness  are  somewhat  exag- 
gerated in  the  drawing. 

—The    Rectum:   Its    Diseases   and   Developmental    Defects. 
By  Sir   Charles   Ball. 

ing  of  the  anus  and  anal  canal  are  freed  entirely  from 
their  underlying  tissues  (Fig.  57).  Ball  advocates  the  use 
of  the  scissors  for  this  work,  but  the  author  has  found  he 


120        AUTHOR'S  TECHNIQUE  FOR  BALL'S  OPERATION. 

can  work  much  more  rapidly  and  with  more  assurance  of 
dividing  all  the  sensory  nerve  twigs  by  the  use  of  a 
sharp  scalpel.  All  bleeding  should  be  controlled  by  pres- 
sure with  dry  gauze,  and  the  flaps  sutured  again  to  the 
surrounding  skin  with  silk  worm  or  No.  2  chromicized 
catgut.  Four  to  six  interrupted  sutures  are  all  that  are 
necessary  for  each  incision.  Firm  pressure  by  wedge- 


Fig.  58. 
Ball's  Operation:  for  Pruritus  Ani. 

The  dotted  lines,  outside  of  the  lines  of  incision,  show  the  area  to 
which  the  wound  is  undercut,  and  the  outside  limits  of  anesthesia  pro- 
duced by  the  operation. 

From  a  photograph  of  one  of  the  author's  cases. 

shaped  gauze  pads  is  brought  to  bear  against  the  region 
operated  upon,  and  the  dressings  held  in  place  by  ad- 
hesive plaster  and  a  T-bandage.  This  operation  by  divid- 
ing all  of  the  sensory  nerve  branches  supplying  the  area 


AFTER  CARE.  121 

most  often  involved  immediately  renders  this  region 
superficially  anesthetic,  and  the  pruritus  is  relieved  at 
once  (Fig.  58).  Cutaneous  sensation  returns  after  a  few 
months,  but  pruritus  is  permanently  relieved. 

The  after  care  consists  in  keeping  the  patient  on  an 
absorbable  liquid  diet  and  keeping  the  bowels  confined 
for  four  or  five  days,  when  they  are  moved  by  an  oil 
enema.  The  parts  are  carefully  washed  and  kept  pro- 
tected at  all  times  by  the  liberal  use  of  compound  stearate 
of  zinc  powder.  The  patient  should  be  kept  in  bed  for  a 
day  or  two  and  then  allowed  to  be  up  and  about,  but  not 
to  resume  his  regular  occupation  for  a  week  or  ten  days. 
In  the  experience  of  the  author,  the  results  following  this 
operation  have  been  most  happy,  particularly  in  those  old 
chronic  cases  where  all  other  forms  of  treatment  have 
been  tried  and  found  wanting. 


CHAPTER  VII. 


ANAL  FISSURE  AND  ULCER. 

Anal  fissure,  or  fissure-in-ano,  is  probably  responsible 
for  more  acute  pain,  suffering  and  discomfort  than  any 
other  lesion  of  its  size  occurring  in  the  human  body.  The 


Fig.  59. 

Fissure   of   the  Anus. 

This  is  a  drawing  of  an  old  chronic  case  occurring  in  the  author's 
practice  and  well  shows  the  extent  to  which  the  ulceration  goes  in  some 
cases.  A  well  developed  sentinel  pile  will  be  seen  at  the  lower  extremity 
of  the  fissure. 


122 


ETIOLOGY. 


123 


fissure,  as  its  name  implies,  is  a  crack  or  elongated  ulcera- 
tion,  occurring  most  frequently  at  the  posterior  commis- 
sure of  the  anus  (Fig.  59). 

Cause.  Fissures  are  caused  by  trauma.  The  trauma- 
tism  may  be  produced  either  by  the  passage  of  an  unusu- 
ally large  stool,  introduction  or  expulsion  of  a  foreign 
body,  sneezing,  coughing,  or  by  faulty  instrumentation. 
Fissures  are  usually  single.  When  more  than  one  is 
present  it  is  an  evidence,  as  a  general  rule,  of  the  presence 
of  tubercular,  gonorrhoeal  or  syphilitic  infection,  or  a 


Fig.  60. 
Multiple  Fissure  in  Ano. 

This   shows  the  extreme  to  which  anal  fissures  may  go  in   cases  suf- 
fering from  wasting  diseases. 

Drawn   from  one  of  the  author's  cases. 


124  ETIOLOGY. 

run-down  condition  caused  by  some  one  of  the  wasting 
diseases  (Fig.  60). 

In  men,  in  90  per  cent  of  the  cases  the  fissure  will  be 
found  at,  or  just  at  one  side  of,  the  posterior  anal  commis- 
sure. In  women,  about  60  per  cent — the  other  location 
being  at,  or  to  one  side,  of  the  anterior  commissure. 

The  reasons  that  the  posterior  commissure  is  the  most 
frequent  location  for  fissure  are :  The  fact  that  on  account 
of  the  concavity  of  the  sacrum  the  curvature  of  the  rectal 
and  anal  canal  is  such,  that  the  greatest  force  during  the 
expulsion  of  the  stool  is  towards  the  posterior  commis- 
sure. Also,  the  fact  must  be  remembered,  that  the  fibres 
of  the  sphincter  ani  muscle  run  parallel  to  each  other  pos- 
teriorily  (see  Fig.  4),  to  the  coccyx;  and  this  is  the  direc- 
tion of  the  anal  line  of  cleavage.  Moreover,  this  is  a  con- 
stant location  for  one  of  the  crypts  of  Morgagni,  and  the 
tearing  down  of  a  semi-lunar  valve  at  this  point  (Fig.  61), 
is  also  an  important  etiological  factor  in  the  production 
of  fissure. 

Any  inflammatory  condition  which  will  cause  a  mois- 
ture and  softening  of  the  anal  skin  will  render  it  more 
liable  to  be  injured  during  a  movement,  and  fissure  pro- 
duced. A  fissure  is,  in  reality,  a  longitudinal  ulcer.  When 
the  fissure  has  been  in  existence  for  some  time,  it  tends 
to  become  chronic  and  the  tissues  surrounding  it  become 
indurated,  and  the  skin  is  pushed  down  in  the  form  of  a 
tag  which  becomes  hypertrophied  (Figs.  59  and  61)  in 
such  a  way  as  to  give  rise  to  a  thick  crescentic  fold  known 
as  the  "sentinel  pile."  Fissures  frequently  are  found  ac- 
companying hemorrhoids,  the  ulceration  being  located  in 
the  sulcus  between  two  hemorrhoidal  masses.  Not  in- 


ETIOLOGY. 


125 


frequently  when  the  fissure  is  of  the  chronic  variety,  it 
is  accompanied  by  a  polypus,  which  by  hanging  down 
into  the  fissure  from  its  upper  extremity,  tends  to  keep 


Fig.   61. 

Fissure  in  Ano   Resulting   From  the  Tearing   Down   of   One   of  the 
Crypts  of  Morgagni  With  the  Formation  of  a  "Sentinel  Pile." 


126  DIAGNOSIS. 

it; '  irritated  and  prevents  it  from  healing.  One  reason 
advanced  for  the  fact  that  fissures  or  ulcerations  in  the 
anal  canal  tend  to  become  chronic  rather  than  to  heal, 
is  the  fact  that  the  anal  canal  is  lined  by  a  layer  of  thin 
transitional  epithelium  which  is  neither  mucous  mem- 
brane nor  skin,  and  is  poorly  supplied  wth  blood.  This 
fact,  and  the  action  of  the  sphincters  keeping  the  parts  in 
motion,  tend  to  prevent  good  healing. 

The  diagnosis  of  fissure  is  comparatively  easy.  A  pa- 
tient presenting  himself  with  a  history  of  sharp,  cutting, 
often  excruciating  pain,  accompanying  the  passage  of  a 
hard  stool,  and  the  appearance  of  hemorrhage  following 
the  passage,  is  in  itself  almost  pathognomonic  of  the 
production  of  a  fissure.  Added  to  this  the  history  of 
pain,  usually  very  severe,  as  well  as  the  appearance  of 
blood  with  each  succeeding  stool,  is  corroborative.  When 
the  patient  also  complains  of  a  beating,  throbbing  pain 
lasting  from  half  an  hour  to  several  hours  following  the 
passage  and  painful  spasmodic  contractions  of  the  anal 
sphincter,  or  Pruritus  Ani,  the  diagnosis  of  fissure-in-ano 
is  almost  conclusive,  without  an  examination.  However 
one  can  never  take  the  diagnosis  of  any  condition  in  the 
anal  or  rectal  region  for  granted,  without  making  a  thor- 
ough examination.  Therefore,  after  obtaining  such  a 
history,  the  patient  should  be  placed  on  the  table  in  the 
lateral  position  for  examination. 

Upon  separating  the  buttocks,  the  first  thing  that  will 
usually  attract  attention,  except  in  acute  cases,  is  the 
presence  of  a  sentinel  pile.  This  gives  a  clue  at  once  to 
the  location  of  the  fissure,  which  will  be  found,  as  above 
stated,  almost  always  at,  or  to  one  side  or  other,  of  the 
posterior  anal  commissure.  Inasmuch  as  the  entire 


DIAGNOSIS  AND  TREATMENT.  127 

sphincter  is  inflamed,  hypertrophied  and  exquisitely 
sensitive  to  the  touch,  it  may  be  necessary,  before  a  satis- 
factory examination  can  be  made,  to  anesthetize  the  parts. 

However,  if  by  gentle  traction  on  the  skin,  just  below 
the  sentinal  pile,  a  red  raw  abrasion  is  disclosed,  extend- 
ing upward  into  the  anal  canal,  the  diagnosis  of  fissure 
is  confirmed.  If  this  procedure  causes  much  suffering  to 
the  patient,  it  had  better  be  abandoned  until  the  sphincter 
has  been  anesthetized  according  to  the  technique  outlined' 
in  Chapter  XV. 

In  cases  which  have  existed  for  some  time,  the  fissure 
instead  of  presenting  a  red  angry  appearance,  may  be 
covered  with  a  grayish  or  yellowish  exudation.  The  rea- 
son that  a  fissure  or  ulceration  of  this  region  is  so  exquis- 
itely tender  is  because  of  the  exposure  of  some  of  the 
numerous  nerve  endings  with  which  this  region  is  so  gen- 
erously supplied.  The  only  other  condition  with  which 
fissure  is  liable  to  be  confounded,  is  hemorrhoids,  and  that 
only  from  the  patient's  standpoint.  Not  infrequently 
practitioners  have  been  led  into  the  error  of  taking  the 
patient's  word  for  the  fact  that  he  was  suffering  from 
hemorrhoids,  because  of  the  symptoms  of  pain  at  stool 
and  hemorrhage;  and  the  author  would  reiterate  at  the 
risk  of  becoming  tiresome,  that  a  rectal  examination  must 
be  made  in  every  case,  when  the  exact  diagnosis  can  be 
easily  made. 

Treatment.  The  treatment  of  fissure  in  ano  resolves 
itself  into  palliative  and  operative.  Many  cases  of  fis- 
sure of  recent  origin  are  entirely  amenable  to  non-surgi- 
cal treatment.  The  first  thing  to  do  is  to  relieve  constipa- 
tion, which  is  done  by  putting  the  patient  on  a  suitable 
diet,  excluding  all  such  articles  as  leave  much  residue  and 


128 


NON-SURGICAL  TREATMENT. 


cause  bulky  stools.  The  administration  of  white  petro- 
leum oil,  suitably  flavored,  in  doses  of  from  four  drachms 
to  an  ounce  daily,  will  soften  the  stools  to  such  an  extent 
as  to  make  them  easy  of  expulsion  and  yet  not  liquid  and 
irritating. 

Where  the  fissure  is  shallow,  and  is  not  accompanied 
by  the  formation  of  a  sentinel  pile,  the  application  of  a 
swab  moistened  in  four  per  cent  eucain  solution,  for  four 
or  five  minutes,  followed  by  the  application  of  pure 
ichthyol  to  the  surface  of  the  fissure,  is  very  efficacious. 


Fig.   62. 

Method   of  Applying   Ointment   to  the  Anus  from  a   Long  Nozzled 
Collapsible  Lead  Tube. 

This  is  repeated  every  second  day.  In  the  meantime  the 
patient  is  instructed  to  carefully  cleanse  the  parts  after 
bowel  movements  and  to  apply,  by  means  of  a  long  noz- 
zled  ointment  tube  (Fig.  62)  the  following: 


NON-SURGICAL  TREATMENT.  129 


Chloretone   _______________________  gr.  xxx 

Thymol  iodide  ____________________  gr.  xx 

Ichthyol  ____________________________  gr.  xxx 

Lanolin  ___________________________  qs.o  ss. 

M.  Ft.  Unguentum. 

In  other  cases,  the  application  of  a  mixture  containing 
10  per  cent  of  ichthyol  and  8  per  cent  of  chloretone  in 
flexible  collodion,  will  be  sufficient.  The  application  is 
made  by  means  of  a  swab,  or  directly  from  the  long  noz- 
zled  ointment  tube;  the  parts  being  separated  with  the 
thumb  and  forefinger  of  one  hand,  while  the  application 
is  made  with  the  other.  Then  the  parts  are  thoroughly 
dried,  and  the  evaporation  of  the  ether  hastened  by  means 
of  the  air  current.  Stearate  of  zinc  powder  is  applied 
and  a  pledget  of  absorbent  cotton  protects  the  parts  from 
the  clothes. 

•  Occasionally,  where  the  fissure  is  very  superficial  and 
consists  merely  of  a  crack  in  the  mucous  membrane,  a 
single  application  of  a  100  per  cent  solution  of  nitrate  of 
silver  will  be  sufficient.  This  acts  by  causing  a  protective 
covering  of  albuminate  of  silver  to  be  formed  and  effects 
the  cure.  Proper  attention  to  the  condition  of  the  bowels, 
cleanliness  and  the  application  of  stearate  of  zinc  powder 
being  all  the  after  care  that  is  required. 

The  daily  application  of  mild  solutions  of  nitrate  of 
silver,  alum,  copper  sulphate  or  the  use  of  the  caustic 
stick  are  not  to  be  advised,  because  they  only  keep  up  the 
irritation  and  destroy  the  new  granulation  tissue  as  fast 
as  it  is  formed.  The  stronger  solution  of  silver  nitrate, 
as  mentioned  above,  by  its  sudden  coagulation  of  the  al- 
bumen of  the  tissues  when  it  comes  in  contact  with  the 


130  SURGICAL  TREATMENT. 

wound,  causes  the  formation  of  an  impermeable  protec- 
tive covering  for  the  granulating  surface  beneath;  and, 
moreover,  is  far  less  painful  than  the  milder  solutions. 
Suppositories  for  the  relief  of  fissure,  do  not  appeal  to 
the  author,  inasmuch  as  fissure  is  always  found  in  the 
anal  canal  and  the  action  of  a  suppository  is  exerted  only 
in  the  lower  rectal  cavity;  he  fails  to  see  where  any  direct 
relief  can  be  obtained  from  suppositories  in  this  condi- 
tion. Moreover,  it  is  doubtful  whether  an  ointment  ap- 
plied with  the  finger  is  of  any  value,  for  it  certainly  can- 
not be  applied  high  enough  to  reach  any  but  the  most 
dependent  portion  of  the  fissure ;  yet  it  is  astonishing  how 
often  the  patient  suffering  with  fissure  is  dismissed  with 
a  prescription  for  an  ointment. 

Surgical  Treatment.  The  best  and  surest  and 
quickest  treatment  for  fissure-in-ano  is  incision  or 
excision.  The  author  knows  of  no  operative  pro- 
cedure in  the  line  of  proctology  from  which  more 
satisfactory  results  are  achieved  than  the  incision 
or  excision  of  an  anal  fissure.  Under  local  anesthesia, 
this  is  very  easily  and  readily  accomplished,  and  the  re- 
sults are  invariably  all  that  could  be  desired.  In  some 
cases,  where  the  fissure  is  of  recent  origin,  not  accompa- 
nied by  much  inflammatory  infiltration  of  the  surround- 
ing tissues,  simple  divulsion  is  all  that  is  necessary  to 
effect  a  cure.  Divulsion  of  the  sphincter,  however,  can 
be  accomplished  to  the  extent  of  temporarily  paralyzing 
the  muscle,  only  by  the  use  of  a  general  anesthetic.  This 
can  be  best,  quickest,  and  most  safely  accomplished  by 
the  use  of  nitrous  oxide,  than  any  other  anesthetic. 

Incision.  The  technique  of  incision  of  anal  fissure 
is  as  follows:  After  anesthetizing  the  sphincter 


TECHNIQUE  OF  INCISION. 


131 


and  dilating  it,  as  outlined  in  the  chapter  on  local 
anesthesia,  a  drachm  or  so  of  one-tenth  of  one  per 
cent  solution  of  eucain  is  injected  below  and  around 
the  fissure  in  such  a  way  as  to  raise  it  up  so 
that  it  is  resting  on  a  "water  bed."  After  wait- 
ing a  minute  or  two  for  anesthesia  to  become  complete, 
an  incision  is  made  from  the  extreme  upper  end  of  the 
fissure  down  through  the  center  and  extending  beyond 
the  lower  extremity  for  a  quarter  of  an  inch  into  the  skin. 
The  incision  should  be  so  made  that  its  upper  or  inner 


Fig.  63. 

Simple  Incision  of  Fissure  in  Right   Posterior  Lateral   Quadrant  of 

Anus. 

extremity  should  be  the  shallowest,  and  it  should  become 
deeper  until  at  the  lower  or  skin  end  it  is  from  one- 
quarter  to  one-half  inch  in  depth,  slanting  in  such  a 
way  that  the  upper  or  shallowest  part  shall  be  the  first 


132  INCISION AFTER  CARE. 

to  heal  and  the  lower  the  last— thus  providing  proper 
drainage.  The  unhealthy  surface  should  be  lightly  cur- 
retted,  a  suppository  containing  two  grains  each  of 
chloretone,  thymol  iodide  and  powdered  opium  inserted, 
and  a  single  strip  of  plain  gauze  placed  in  the  wound. 

At  the  end  of  24  hours  the  gauze  is  removed,  but  the 
patient's  bowels  not  allowed  "to  move  for  three  days  at 
least.  In  the  meantime,  he  is  kept  on  liquid  diet  and  the 
administration  of  white  petroleum  oil  is  started  on  the 
evening  of  the  second  day,  so  that  the  first  stool  will  be 
soft  and  unirritating.  It  is  advisable  on  the  evening 
before  a  stool  is  desired,  to-  administer  a  level  teaspoon- 
ful  of  compound  licorice  powder,  and  the  first  thing  the 
following  morning,  to  inject  through  a  small  rubber 
catheter,  six  or  eight  ounces  of  olive  oil  into  the  rectum 
to  insure  a  soft  and  easy  movement. 

The  after  care  consists  in  keeping  the  parts  clean,  the 
bowel  movements  soft,  and  the  patient  up  and  about 
after  the  first  24  hours.  If  granulations  become  flabby 
or  unhealthy  in  appearance,  a  single  application  of  100 
per  cent  nitrate  of  silver  is  usually  sufficient  to  stimulate 
healthy  healing.  On  the  other  hand,  if  the  patient  is  in 
a  run-down  condition  and  the  healing  slow,  the  insertion 
of  a  one-half  inch  strip  of  gauze  soaked  in  bovinine.  twice 
daily,  will  nourish  the  healing  tissues  and  bring  about  a 
speedy  result. 

While  in  many  cases  this  procedure  will  be  sufficient,  it 
will  not  answer  where  the  fissure  is  of  long  standing,  or 
if  surrounded  by  an  area  of  infiltration,  or  where  there  is 
a  well  developed  sentinel  pile  or  a  polypus  accompanying 
the  fissure.  Ofter  a  fissure  after  incision  will  not  heal, 
because  of  the  fact  that  the  mucous  membrane  dips  down 


AUTHOR'S  OPERATION  FOR  EXCISION  OF  FISSURE.      133 

into  the  wound  and  tends  to  keep  its  edges  apart.  To 
obviate  this,  and  to  make  sure  that  all  the  diseased  tis- 
sues are  removed,  the  author  excises  instead  of  incises. 
when  operating  for  fissure  in  ano. 

Author's  Operation.  With  the  patient  prepared  and 
anesthetized  as  for  the  incision  operation  (with  the  excep- 
tion that  the  area  of  infiltration  anesthesia  is  made  more 
extensive  so  as  to  include  all  the  induration  surrounding 
the  fissure),  he  proceeds  as  follows:  The  fissure  is 
grasped  at  its  upper  extremity  with  sharp  toothed  for- 


Fig.  64. 

Sharp  Toothed  or  Pronged  Forceps. 

This  is  a  very  useful  instrument  in  many  ano-rectal  operations  and 
while  originally  designed  as  a  tonsil  forcep,  is  of  great  value  in  proc- 
tologic  work. 

ceps  and  two  longitudinal  incisions  are  made,  one  on 
either  side  of  the  fissure,  starting  from  one-eighth  to  one- 
fourth  inch  to  either  side  of  its  upper  or  inner  extremity 
and  being  made  in  such  manner  that  they  meet  underneath 
the  fissure  in  its  median  line,  forming  a  V-shaped  trench 
(Fig.  65),  as  it  were,  which  is  one-eighth  of  an  inch  deep 
at  its  upper  extremity  and  one-fourth  of  an  inch 
wide;  and  at  the  outer  or  skin  portion  its  width  is 


134 


AUTHOR'S  TECHNIQUE. 


from  one-half  to  three-fourths  of  an  inch  and  its  depth 
from  one-fourth  to  one-half  inch.  This  disposes  of 
the  entire  fissure,  with  its  indurated  edges,  and  the 
sentinel  pile  as  well.  It  also  allows  of  the  fissure 


FFC.B 


Fig.  65. 
The  Author's  Technique  for  the   Excision   of  Anal   Fissure. 

A.  The  dotted  lines  show  the  line  of  incision  both  on  skin  surface  and 

mucous   membrane. 

B.  Showing  V-shaped  bed  left  after  removal   of  the   flap  containing  the 

fissure ;    the   dotted   lines    show   the   shape   and   direction   of   the 
incision  inside  of  the  anus. 

healing  quickest  at  the  bottom  and  prevents  any  over- 
growth of  the  mucous  membrane  or  dipping  down 
of  the  edges.  If  a  polypus  is  situated  at  the  upper 
extremity,  the  incisions  are  carried  up  to  include  it. 
and  as  the  fissure  is  dissected  up  from  below,  a  liga- 


EXCISION   OF  AXAL   ULCER. 


135 


ture  is  thrown  around  the  base  of  the  polypus,  tied, 
and  the  fisure  and  polypus  en  masse  cut  away.  The  after- 
treatment  is  the  same  as  outlined  for  the  incision  opera- 


Fig.  66. 

Operation   for    Excision   of   Anal   Ulcer. 

Note   the   manner    in    which    the    incisions    are    brought   to   a   point   at 
upper  and  lower  extremities  of  wound. 


136  ANAL  ULCER TREATMENT. 

tion.  This  operation,  in  the  hands  of  the  author  has 
been  so  satisfactory  that  it  is  his  routine  treatment  for 
all  fissures  not  amenable  to  non-surgical  treatment. 

Anal  Ulcer.  Whatever  has  been  said  regarding  fis- 
sure in  ano  in  regard  to  treatment  by  non-surgical  meas- 
ures is  equally  applicable  to  anal  ulcer,  the  only  distinc- 
tion between  the  two  conditions  being  a  question  of  the 
shape  of  the  ulceration — the  fissure  being  elongated,  while 
the  other  ulcers  of  the  rectum  are  round  or  irregular  in 
outline.  In  ulcers  which  do  not  respond  to  the  applica- 
tions advocated  for  fissure,  the  injection  of  a  few  drops 
of  one-tenth  of  one  per  cent  eucain  solution  under  the 
ulcer  is  advisable,  and  a  light  curetting  of  its  surface 
will  often  be  followed  by  marked  relief.  Where  the  ulcer 
is  of  long  standing,  the  excision  of  the  indurated  tissues 
surrounding  as  well  as  the  ulcer  itself  should  be  accom- 
plished following  the  same  technique  as  outlined  for  the 
excision  of  fissure,  varying  the  direction  of  the  incision 
to  correspond  to  the  shape  of  the  ulcer  (Fig.  66). 

The  after-treatment  following  excision  of  an  anal  ulcer 
is  exactly  the  same  as  that  outlined  above,  following  fis- 
sure. It  is  the  watchful  after-care  of  the  conscientious 
physician  following  many  of  these  minor  anal  operations 
which  is  responsible  for  the  good  results — for  often  a 
well  executed  operation  is  nullified  in  its  results  by  neg- 
lectful, slovenly  or  misdirected  after-care.  Oftentimes 
the  after-care  of  patients  following  these  operations,  is 
over-done  rather  than  the  reverse,  and  meddlesome  inter- 
ference accomplishes  more  harm  than  the  operation  does 
good. 


CHAPTER  VII. 


ABSCESS  OF  THE  ANO-EECTAL  BEGION. 

The  region  of  the  anus  and  rectum  is  peculiarly  prone 
to  infection  and  abscess  formation,  for  several  reasons: 
The  unusual  amount  of  cellular  tissues  surrounding  the 
rectum;  the  lavish  blood  supply  of  this  region;  the  con- 
stant presence  in  the  rectum  of  pyogenic  bacteria;  the 
traumatism  from  unusually  large  or  hard  feces,  foreign 
bodies  which  have  been  swallowed,  such  as  spicules  of 
bone,  fruit  pits,  seeds,  and  other  articles  which  have  been 
ingested.  The  rich  lymphatic  supply  of  this  region  is  of 
no  small  moment  in  the  production  and  extension  of  sep- 
tic inflammation.  Skin  diseases  around  the  anus,  partic- 
ularly those  which  affect  the  hair  follicles,  inflammation 
of  external  hemorrhoids,  the  irritation  from  clothing  or 
harsh  detergents,  disease  of  the  crypts  of  Morgagni,  rec- 
tal ulceration  and  anal  fissure — all  may  form  the  starting 
point  for  the  formation  of  an  abscess  in  this  region. 

Septic  infections  of  the  ano-rectal  region  have  been  di- 
vided into  different  classes  by  different  authors.  Tuttle 
classifies  them  as  follows : 


137 


138 


CLASSIFICATION". 


Circumscribed 
Inflammations 
or  Abscesses 


f  Subtegumentary. 
Superficial  -i  Tegumentary. 
I  Ischio-Rectal. 


Profound 


Diffuse   Inflammations 


f  Retro-Rectal. 
J  Superior  Pelvi- 

Rectal. 
[  Interstitial. 

f  Diffuse  Perirectal 
Cellulitis. 

I  Gangrenous  peri- 
rectal  Cellulitis. 


Of  the  circumscribed  inflammations  or  abscesses,  only 
those  which  are  located  below  the  levator  ani  muscle  are 
amenable  to  treatment  under  local  anesthesia  and  will  be 
considered  by  the  author  under  the  head  of  tegumentary 
or  perineal  abscesses;  peri-anal,  marginal,  or  subtegu- 
mentary  abscesses ;  submucous  or  intermural,  and  ischio- 
rectal  abscesses. 

Tegumentary  Abscesses.  ;  The  tegumentary,  or  peri- 
neal abscesses,  are  really  nothing  more  than  pustules,  or 
furuncles  of  the  skin  surrounding  the  anal  orifice,  or. a 
pustular  inflammation  of  the  hair  follicles.  They  may  be 
brought  about  by  anything  which  causes  irritation  of  the 
parts,  such  as  extensive  perspiration;  discharge  from  the 
anus  or  vagina;  chafing  from  the  clothing;  infection  by 
the  finger-nails  in  scratching;  personal  uncleanliness,  or 
the  use  of  harsh  detergent  materials.  The  condition  may 
range  from  a  simple  acne  of  the  parts  to  the  formation 
of  numbers  of  typical  boils.  These  cause  a  slight  sense 
of  irritation,  smarting  or  itching,  and  cause  more  discom- 
fort when  the  patient  is  sitting  or  walking  than  any  inter- 
ference with  the  function  of  the  bowel  itself.  Occasion- 


ANO-BECTAL  ABSCESSES. 


139 


Fig.  67. 
Ano-Rectal  Abscesses. 

1.  Submucous    or    intramural    abscess. 

2.  Ischio-rectal   Abscess. 

3.  Marginal    or    Subcutaneous   Abscess. 

4.  Tegumentary   or   Cutaneous   Abscess. 


10 


140  TEGUMENTARY  ABSCESSES. 

ally  several  of  these  small  abscesses  may  run  together, 
forming  a  typical  carbuncle.  This,  however,  is  rather 
rare  in  this  region.  There  is  usually  a  slight  rise  of  tem- 
perature, a  degree  or  two  at  outside;  and  more  or  less 
irritability  of  the  patient's  temper.  There  are  no  consti- 
tutional symptoms. 

Diagnosis. — With  the  patient  in  the  lateral  posture, 
these  abscesses  will  be  seen  occurring  either  singly  or  in 
groups  as  rounded  reddened  swellings  from  the  size  of  a 
large  pin  head  to  a  hazel  nut ;  with  or  without  a  point  of 
suppuration  showing. 

Treatment. — The  treatment  consists  of  spraying  each 
abscess  with  ethyl  chloride  and  opening  with  a  sharp  bis- 
toury. After  allowing  the  pus  to  escape,  the  cavity  is 
swabed  with  95%  carbolic  acid.  Daily  washing  of  the 
part  with  warm  saturated  solution  of  boracic  acid  and 
dressing  with  boro-chloretone  powder  will  usually  be  all 
that  is  necessary  in  the  line  of  after-treatment.  The 
parts  should  be  washed  after  defecation  and  protected 
with  sterile  gauze  and  the  clothing  worn  loose  so  that 
there  is  no  pressure  or  chafing  from  that  source  to  keep 
up  the  irritation. 

If  there  is  a  tendency  for  these  little  skin  infections  to 
recur,  it  is  advisable  to  treat  the  patient  with  a  bacterial 
vaccine  made  from  the  predominant  germ  responsible  for 
the  infection.  In  most  cases  this  will  be  found  to  be  the 
staphylococcus  pyogenes  aureous  or  albus. 

Subtegumentary  or  Marginal  Abscesses.  The  most 
common  abscess  developing  in  the  region  of  the  anus 
is  that  which  occurs  deeper  under  the  layers  of  the  skin  or 
lining  membrane  of  the  anus,  described  in  the  above  clas- 
sification as  subtegumentary,  also  known  as  peri-anal  or 


SUBTEGUMENTAEY  OB  MAEGINAL  ABSCESSES.  141 

marginal  abscesses;  also  as  subcutaneous,  submucous  or 
intra-mural,  depending  upon  the  kind  of  tissue  under 
which  the  abscess  develops.  While  often  their  start- 
ing point  can  be  traced  to  a  fissure  or  ulcer,  a  broken 
down  thrombotic  pile,  or  a  diseased  crypt,  or  the  trau- 
matism  due  to  a  bit  of  bone  or  other  swallowed  foreign 
body ;  nevertheless,  in  many  cases,  the  point  of  infection 
cannot  be  determined — leading  us  to  the  conclusion  that 
the  abscess  is  caused  by  extension  through  the  lymphatic 
system,  from  some  more  or  less  remote  injury  or  disease 
in  this  region.  They  may  occur  at  any  age,  but  are  less 
common  in  children. 

Symptoms. — Occasionally  abscesses  which  occur  in  this 
region,  particularly  the  sub-mucous  variety,  have  formed 
and  gone  on  to  a  considerable  size  without  causing  any 
other  symptoms  than  a  sense  of  uncomfortableness  or 
fullness  in  the  lower  rectum,  noticed  particularly  during 
defecation.  Usually,  however,  the  patient  complains 
first  of  sharp  darting  pains  in  the  rectum,  which  is  soon 
followed  by  an  aching,  throbbing  pain  which  is  persistent 
and  gradually  increasing.  This  aching  extends  to  the 
sacral  region  and  the  pain  often  shoots  down  one  or  both 
legs,  even  to  the  heel.  The  patient  often  complains  of 
difficulty  of  urination.  Defecation  is  always  painful  and 
on  account  of  the  feeling  of  fullness  in  the  rectum,  is  put 
off  by  the  patient  as  long  as  possible.  The  pulse  rate 
increases  in  rapidity  and  the  temperature  rises  from  one 
to  four  degrees.  The  patient  cannot  sit  comfortably  and 
rests  his  weight  on  one  buttock  or  the  other ;  a  character- 
istic posture  of  patients  suffering  from  acute  rectal  dis- 
ease (See  Fig.  8),  which  is  almost  diagnostic  in  itself. 


142  .SUBMUCOUS  ABSCESS. 

An  abscess  may  often  come  on  in  from  24  to  36  hours, 
and  occasionally  will  rupture  before  the  patient  is  really 
aware  of  the  severity  of  the  trouble.  These  are  the  cases 
which  are  most  frequently  followed  by  fistula  formation. 

Examination. — With  the  patient  in  the  lateral  posture, 
often  nothing  can  be  determined  by  ocular  inspection 
unless  the  abscess  be  situated  at  or  outside  the  margin 
of  the  anus — when  it  will  appear  as  a  rounded  swelling, 
reddened  in  color,  situated  most  often  at  one  side  or 
other  of  the  posterior  anal  commissure.  On  digital  ex- 
amination, its  outline  can  be  definitely  determined  and 
its  extent  noted.  If  seen  early,  a  definite  point  of  fluctu- 
ation cannot  be  made  out,  but  the  whole  abscess  has  a 
hard,  doughy  feel.  It  is  extremely  painful  to  the  touch 
and,  on  account  of  the  accompanying  spasmodic  contrac- 
tion of  the  sphincter  muscle,  it  is  often  very  hard  to 
examine. 

Submucous  Abscess.  The  submucous  or  inter-mural 
variety  occurs  underneath  the  mucous  membrane  cover-' 
ing  the  lower  rectum,  and  may  be  found  at  any  point  in 
the  circumference  of  the  rectum.  Those  located  in  the 
anterior  wall  are  usually  accompanied  by  disturbances 
of  urination.  In  factr  often  times  patients  are  unable  to 
urinate  at  all  and  have  to  be  catheterized.  This  variety 
is  diagnosed  by  digital  examination — the  well  lubricated 
finger,  gently  inserted  through  the  anus  while  the  patient 
is  asked  to  bear  down.  A  rounded  mass  may  be  felt  with- 
in an  inch  or  inch  and  a  half  of  the  anal  outlet,  either  of 
a  doughy  consistency  or  distinctly  fluctuating.  By  gently 
sweeping  the  finger  from  side  to  side,  the  outlines  can  be 
made  out  and  its  extent  determined.  With  the  short  ano- 
scope,  the  diagnosis  can  be  further  confirmed  (Fig.  68), 


SUBMUCOUS  ABSCESS DIAGNOSIS  AND  TREATMENT.      143 

and  not  infrequently  the  point  of  infection  determined. 
Occasionally,  the  abscess  may  extend  down  to  the  integu- 
ment outside  of  the  anus,  forming  a  submuco-cutaneous 
abscess. 


Fig.  68. 
Proctoscopic  View  of  Submucous  Abscess  of  the  Rectum. 

Diagnosis. — The  diagnosis,  after  both  digital  and  ocu- 
lar examination,  is  very  evident.  Given  the  symptoms  of 
rise  in  temperature,  rapid  pulse,  aching,  throbbing,  pain 
coming  on  more  or  less  suddenly  in  the  region  of  the  anus 
or  lower  rectum  and  remaining;  becoming  more  persist- 
ent and  increasing  in  severity,  with  the  presence  of  a  cir- 
cumscribed painful  swelling,  makes  the  diagnosis  of  ab- 
scess in  this  region  conclusive. 

Treatment. — The  treatment  of  the  sub-cutaneous  or 
marginal  variety  is  very  satisfactorily  accomplished  un- 


144  TREATMENT  OF  SUBCUTANEOUS  ABSCESS. 

der  local  anesthesia.  If  the  abscess  is  situated  at  or  below 
the  juncture  of  the  anus  and  rectum,  it  will  not  be  nec- 
essary to  anesthetize  the  sphincter  muscle.  With  the 
patient  in  the  lateral  or  lithotomy  position,  the  parts  are 
scrubbed,  shaved  and  sterilized,  and  the  skin  over  the 
abscess  injected  with  i/o  of  one  per  cent  solution  of  beta 
eucain  lactate.  A  point  a  half-inch  below  the  abscess 
proper  is  selected  for  the  first  injection,  and  the  injection 
carried  upward  so  that  a  wheal  or  welt  a  quarter  of  an 
inch  to  half  an  inch  wide,  and  extending  the  entire  length 
of  the  abscess,  is  formed.  After  waiting  two  minutes  for 
the  anesthetic  to  take  effect,  an  incision  is  made  from  one 
extreme  of  the  abscess  to  the  other  in  a  direction  radiat- 
ing from  the  anus,  and  the  pus  allowed  to  escape.  It  is 
then  syringed  out  with  sterile  water  or  normal  salt  solu- 
tion, and  after  breaking  down  any  dividing  walls,  so  as 
to  convert  the  abscess  into  one  cavity,  it  is  swabbed  out 
with  equal  parts  of  tincture  of  iodine  and  carbolic  acid, 
a  light  gauze  drain  inserted,  and  a  sterile  dressing  ap- 
plied. The  patient  is  not  allowed  to  arise  from  the  table 
for  five  or  ten  minutes  after  the  operation,  when  he  is 
slowly  assisted  to  his  feet,  and  after  a  few  minutes  in  a 
chair  will  be  able  to  go  about  his  way. 

It  is  advisable  to  keep  the  patient  on  an  absorbable 
diet  for  a  couple  of  days  and  not  allow  the  bowels  to 
move  during  that  time.  The  wound  should  be  dressed 
daily,  being  syringed  with  plain  sterile  water  or  salt  so- 
lution and  lightly  packed  with  gauze.  When  the  author 
says  lightly  packed,  he  means  the  gauze  should  be  in- 
serted sufficiently  firm  to  keep  the  wound  edges  well  sep- 
arated and  yet  touching  against  the  lining  of  the  cavity 


TKEATMENT  OF  SUBMUCOUS   ABSCESS.  145 

proper  so  lightly  as  not  to  interfere  with  its  contraction 
during  the  healing  process. 

At  the  end  of  the  fourth  or  fifth  day  in  the  average  case 
the  packing  can  be  dispensed  with  and  a  strip  of  gauze 
inserted  for  drainage  and  merely  to  keep  the  wound 
edges  apart.  The  best  protective  powder  to  use  to  keep 
the  discharge  from  irritating  the  surrounding  skin  is 
compound  stearate  of  zinc  with  balsam  peru  or  boric  acid. 


Fig.  69. 

DeVilbiss  Rectal  Speculum. 

This  instrument  is  useful  in  many  anal  operations,  on  account  of  the 
fact  that  its  blades  may  be  opened  parallel  to  each  other  and  it  can  be 
made  self-retaining. 

When  the  abscess  is  of  the  sub-mucous  variety  and  sit- 
uated above  the  internal  sphincter,  it  will  be  necessary  to 
anesthetize  the  sphincter  according  to  the  technique  out- 
lined in  Chapter  XV.  After  washing  out  the  rectum  with 
saturated  solution  of  boracic  acid,  the  patient  is  placed 
either  in  the  lithotomy  position,  if  the  abscess  is  situated 
on  the  anterior  wall;  or  the  lateral  position,  if  located 
on  the  posterior  or  lateral  wall.  After  the  parts  are 
washed,  shaved  and  sterilized  and  the  sphincter  anes- 
thetized, it  is  slowly  dilated  and  a  Sims  retractor  in- 
serted at  a  point  opposite  the  abscess  and  held  by  an 
assistant.  In  the  absence  of  an  assistant,  a  De  Vilbiss 
rectal  speculum  (Fig.  69)  will  answer,  as  it  is  self  retain- 
ing. The  mucous  membrane  covering  the  abscess  is 


146  TREATMENT  OF  SUBMUCOUS  ABSCESS. 

injected  with  a  1-10  of  one  per  cent  solution  of  eucain 
lactate  or  sterile  water  until  the  tissues  are  blanched 
over  tjie  entire  abscess. 

After  waiting  two  minutes  for  the  anesthetic  to  take 
effect,  the  abscess  is  opened  by  a  longitudinal  incision 
extending  from  its  extreme  upper  end  down  to  a  half  inch 
below  its  lower  extremity.  The  pus  is  allowed  to  drain 
out,  when  it  is  syringed  with  normal  saline  solution  or 
sterile  water.  All  dividing  walls  are  broken  down  so 
that  the  abscess  is  converted  into  one  cavity.  It  is  then 
swabbed  out  with  95%  carbolic  acid  or  equal  parts  of 
carbolic  acid  and  iodine,  and  packed  with  gauze,  which 
should  extend  out  through  the  anus.  In  some  cases  it  is 
advisable  to  insert  a  rubber  drainage  tube  about  the  size 
of  a  lead  pencil,  which  tube  should  also  extend  an  inch  out- 
side of  the  anal  canal. 

The  after-care  is  similar  to  that  advised  for  the  sub- 
cutaneous variety,  especial  care  being  taken  to  see  that 
the  abscess  is  kept  healing  from  the  bottom,  and  that  no 
ramifications  form  during  the  healing  process.  The  pa- 
tient is  allowed  to  be  up  and  about  immediately  after  the 
operation,  and  is  properly  kept  up  on  account  of  better 
drainage  in  the  upright  position.  It  is  this  variety  of 
abscess  which  if  allowed  to  open  without  surgical  inter- 
ference forms  the  blind  internal  fistula.  It  is  an  im- 
portant thing  to  remember  in  this  variety  of  abscess  par- 
ticularly, that  the  incision  should  be  carried  well  below 
the  lower  extremity  of  the  abscess,  so  as  to  allow  of  good 
drainage. 

Ischio-Rectal  Abscess.  Ischio-rectal  abscesses  are  the 
most  severe  variety  which  can  be  treated  under  local  an- 
esthesia, and  not  all  of  these,  by  any  means,  are  favor- 


ISCIIIO-RECTAL,  ABSCESS ETIOLOGY SYMPTOMS.         147 

able  cases.  The  author  would  lay  down  the  rule  that  no 
abscess  of  the  ischio-rectal  region  ivhose  upper  extremity 
is  over  two  inches  from  the  anal  skin,  and  whose  extent, 
size  and  location  cannot  be  definitely  outlined  by  bi-man- 
nal  palpation,  should  be  operated  on  unless  under  a  gen- 
eral anesthetic. 

Ischio-rectal  abscesses  start,  grow  and  extend  with 
great  rapidity  on  account  of  the  loose  cellular  tissue  in 
which  they  form,  which  offer  little  or  no  resistance  to 
iheir  spread.  They  occur  at  either  one  side  or  the  other 
of  the  rectum,  and  occasionally  surround  it.  They  are 
formed  either  from  the  puncture  of  the  rectal  walls  by 
spicules  of  bone,  bristles,  or  other  sharp  foreign  sub- 
stances which  are  swallowed;  or  from  diseased  Morgag- 
nian  crypts  or  infection  which  is  carried  by  the  lymph- 
atic system.  They  have  been  known  to  follow  operations 
upon  the  rectum  and  anus,  or  injury  through  faulty  in- 
strumentation in  making  a  rectal  examination. 

Symptoms. — The  constitutional  symptoms  are  similar 
to  those  which  accompany  the  subcutaneous  or  submucous 
abscesses  with  the  exception  that  the  pain  is  more  deep- 
seated,  the  sacral  aching  more  severe,  and  the  symptoms 
in  general  approaching  more  nearly  that  of  a  general 
septic  infection.  The  patient  often  suffers  from  chills 
with  a  high  fever,  severe  headaches,  backache,  fetid 
breath,  languor,  loss  of  appetite,  and  more  or  less  pros- 
tration. The  pain  localizes  itself  to  one  side  or  the  other 
of  the  rectum  unless  there  is  a  simultaneous  formation 
of  abscesses  on  both  sides.  Defecation  is  so  painful  that 
the  patient  gives  up  all  attempts  at  it  and  frequently  is 
not  able  to  urinate  as  well.  If  the  abscess  has  existed 
longer  than  48  hours  or  so,  some  redness  of  the  skin  will 


ISCHIO-EECTAL   ABSCESS DIAGNOSIS. 


be  met  with,  varying  in  degree  according  to  the  nearness 
to  the  integument  of  the  location  of  the  abscess. 


Fig.   70. 
Line  of  Incision  for  Opening  an  Ischio-Rectal  Abscess. 

From  a  photograph  of  one  of  the  author's  cases. 

Diagnosis. — Bi-manual  rectal  palpation  with  one  fin- 
ger in  the  rectum  and  the  other  hand  pressing  towards  it 
just  outside  of  the  anus  (Fig.  70)  will  disclose  a  hard 
elongated  mass,  often  pear-shaped,  which  is  extremely 
painful,  and  gives  the  characteristic  doughy  or  boggy  feel 
of  an  abscess.  A  point  of  fluctuation  oftentimes  can  be 
made  out  at  either  extremity  of  the  abscess. 

The  diagnosis  is  readily  made  by  bi-manual  examina- 
tion.   The  swelling  caused  by  the  abscess  may  be  so  great 


ISCHIO-RECTAL  ABSCESS TREATMENT.  149 

that  it  is  practically  impossible  to  introduce  the  procto- 
scope into  the  rectum. 

Treatment. — After  the  rectum  has  been  flushed  with  a 
saturated  solution  of  boracic  acid,  the  patient  is 
placed  in  the  lithotomy  or  lateral  position,  according  to 
the  location  of  the  abscess,  and  the  parts  washed,  shaved 
and  sterilized.  The  sphincter  is  anesthetized  according 
to  the  technique  outlined  in  Chapter  XV,  and  the  skin 
over  the  abscess,  as  well  as  the  anal  lining  membrane,  is 
infiltrated  with  one-half  of  one  per  cent  solution  of  eu- 
cain  lactate.  After  the  infiltration  of  the  skin,  the  sub- 
cutaneous tissues  down  to  the  abscess  cavity  are  inject- 
ed with  one-tenth  of  one  per  cent  solution  of  eucain  lac- 
tate, care  being  taken  not  to  penetrate  the  abscess  cav- 
ity with  the  hypodermic  needle.  The  infiltration  should 
be  carried  well  into  the  lower  rectum.  A  Sims  retractor 
is  inserted  at  a  point  opposite  the  abscess  and  held  by  an 
assistant,  or  the  De  Vilbiss  speculum  used,  and  opened 
to  its  fullest  extent.  With  a  sharp  pointed  bistoury  an 
incision  is  made  from  the  outermost  point  of  the  abscess 
on  the  skin  towards  the  anus,  so  that  the  incision  is  at 
right  angles  to  the  anal  canal.  The  opening  should  be 
made  free  enough  so  as  to  thoroughly  drain  the  abscess 
cavity,  and,  if  necessary,  should  be  extended  through  the 
sphincters  into  the  anus. 

Where  the  abscess  cavity  can  be  well  exposed  by  an 
incision  which  stops  short  of  the  sphincters  and  there 
are  no  ramifications  of  the  cavity,  it  will  not  be  necessary 
to  enter  the  rectum,  and  the  author  as  a  rule  would  cau- 
tion against  making  an  opening  in  the  rectum  unless  a 
communication  already  exists  in  the  form  of  a  fistula. 
All  trabeculae  and  partition  walls  should  be  broken  down 


150  ISCHIO-RECTAL  ABSCESS TREATMENT. 

so  that  the  abscess  is  converted  into  one  cavity,  and  it 
should  be  well  irrigated  with  saline  solution  or  sterile 
water.  The  incision  at  the  lower  point  of  the  abscess 
cavity  should  be  as  wide  or  wider  than  the  cavity  itself. 
After  irrigating  the  cavity,  sufficiently  gauze  soaked  in 
Balsam  Peru  should  be  gently  inserted  so  as  to  keep  its 
walls  apart  and  lightly  packed.  A  dressing  is  applied 
and  the  patient  advised  to  keep  in  the  recumbent  posi- 
tion, lying  preferably  on  the  side  where  the  abscess  is 
located  for  24  hours. 

At  the  end  of  that  time,  the  packing  is  removed  and 
about  two-thirds  of  the  quantity  of  gauze  used  in  the  first 
dressing  inserted  lightly.  At  each  succeeding  daily  dress- 
ing the  amount  of  gauze  is  lessened  until  the  abscess  cav- 
ity has  healed  up  from  the  bottom.  If  the  granulations 
become  flabby  or  unhealthy  at  any  time,  they  should  be 
touched  up  with  a  stick  of  copper  sulphate  or  a  swab 
moistened  with  25%  solution  of  silver  nitrate.  The  ap- 
plication of  pure  ichthyol  every  second  or  third  day,  while 
somewhat  painful,  is  of  extreme  value  in  promoting  good 
granulation. 

Where  it  has  been  found  necessary  to  carry  the  incision 
into  the  rectum  and  sever  the  sphincter,  care  should  be 
taken  to  arrange  the  packing  in  such  a  way  as  to  pre- 
vent the  skin  or  mucous  membrane  from  growing  down 
into  the  wound,  thus  preventing  the  reuniting  of  the 
sphincter  as  the  abscess  cavity  heals. 

If  this  should  happen,  however,  in  spite  of  all  precau- 
tions, anesthetize  the  part  by  the  application  of  a  swab 
soaked  in  four  or  five  per  cent  eucain  solution  for  five 
minutes,  keeping  up  pretty  steady  pressure  on  the  parts. 
Then  with  a  pair  of  sharp  pointed  scissors  curved  on 


ISCHIO-RECTAL  ABSCESS TREATMENT.  151 

the  flat,  trim  back  all  redundant  tissue  to  the  surface  of 
the  skin  or  mucous  membrane  as  the  case  may  be. 

In  the  treatment  of  all  suppurative  conditions  of  the 
ano-rectal  region,  the  author  would  caution  his  readers 
to  refrain  from  attempting  to  operate  on  any  case  in 
which  there  is  the  slightest  doubt  of  his  ability  to  com- 
plete the  operation  under  local  anesthesia.  One  must  be 
sure  of  the  size,  location  and  extent  of  the  abscess,  and 
it  must  be  definitely  outlined  and  definitely  circumscribed 
in  order  to  be  amenable  to  treatment  under  local  anes- 
thesia. 


CHAPTER  IX. 


FISTULA  IN  ANO. 

A  fistula  may  be  described  as  a  tubular  suppurating 
tract  communicating  with,  or  connecting  the  mucous  mem- 
brane of  the  anus  or  rectum,  and  the  integument  contig- 
uous to  the  anal  outlet.  Fistulae  are  of  several  different 
varieties,  which  will  be  described  below.  A  fistula  is  the 
result  of  an  abscess  in  the  anal  region  which  has  either 
been  untreated  and  allowed  to  rupture  of  itself,  or  when 
opened  by  the  surgeon  has,  through  insufficient,  careless 
or  improper  after-treatment,  been  allowed  to  contract 
without  being  made  to  heal  from  the  bottom.  The  only 
exception  would  be  a  fistula  caused  from  a  puncture 
wound,  either  traumatic  or  surgical. 

Fistula  in  ano  is  often  spoken  of  as  either  tubercular 
or  non-tubercular.  While  the  author  realizes  that  tuber- 
culosis is  a  factor  to  be  seriously  considered  in  the  dis- 
cussion of  fistula  in  ano,  he  will  reserve  his  remarks  on 
this  particular  variety  of  fistula  until  further  on  in  the 
chapter.  What  is  said  regarding  fistula  in  ano  below, 
therefore,  must  be  understood  to  mean  the  non-tubercu- 
lar varieties. 

The  reason  that  an  abscess  degenerates  into  a  fistula 
in  this  region  rather  than  completely  heal,  is  due  to  two 
factors  peculiar  to  its  location.  The  most  important  is 

152 


CLASSIFICATION  OF  FISTULAE.  153 

the  fact  that  due  to  the  natural  motion  of  the  anus  and 
rectum  in  the  act  of  expulsion  of  gas  or  feces,  and  the 
dilation  and  contraction  of  the  sphincter  muscle,  the 
parts  are  not  allowed  to  remain  at  rest,  and  the  surfaces 
are  prevented  from  adhering  to  each  other.  Added  to 
this  is  the  important  fact  that  mucus  and  feces  enter  the 
abscess  cavity  from  the  rectum  and  their  constant  pass- 
age tends  to  keep  the  tract  open  and  prevent  healing.  A 
fistula  therefore  is  in  reality  the  tubular  contracted  re- 
mains of  an  abscess,  and  is  lined  by  a  pyogenic  membrane 
as  was  its  parent  abscess. 

Varieties. — The  variety  of  a  fistula  depends  on  the  lo- 
cation and  kind  of  abscess  which  preceded  it.  They  are 
divided  by  some  authors  into  complete  and  incomplete. 
A  complete  fistula  being  one  which  gives  a  direct  com- 
munication between  the  bowel  and  the  surface  of  the  skin, 
somewhere  in  the  region  of  the  anal  opening.  An  incom- 
plete fistula  is  one  which  has  an  opening  either  into  the 
bowel  alone  or  one  which  opens  through  the  integument 
only.  Complete  fistulae  (leaving  out  of  consideration 
those  which  communicate  with  other  organs,  such  as  the 
bladder,  vagina  or  urethra)  are  divided  into  horse-shoe 
fistulae  and  multiple  fistulae.  The  horseshoe  fistula  is 
characterized  by  its  having  one  opening  in  the  anal  canal, 
usually  situated  between  the  sphincters  at  the  posterior 
commissure;  and  surrounding  the  anus,  communicates 
with  the  skin  by  two  openings — one  on  either  side  of  the 
anus.  A  multiple  fistula  is  one  which  has  one  or  more 
internal  openings  and  numerous  branching  channels  open- 
ing by  many  external  openings  on  the  skin.  The  incom- 
plete varieties  are  known  as  the  blind  internal  fistulae, 
which  are  characterized  by  the  fact  that  they  open  into 


154  SIMPLE,  COMPLETE,  FISTULA SYMPTOMS,  DIAGNOSIS. 

the  bowel  only,  and  blind  external  fistulae,  whose  only 
opening  is  on  the  skin. 

A  form  of  fistula  known  as  the  sub-mucous  fistula  is 
one  which  has  two  openings,  both  opening  on  mucous 
membrane,  and  is  usually  found  just  inside  the  anal 
canal.  The  most  common  location  for  the  internal  open- 
ing of  a  fistula  is  at  the  posterior  commissure  of  the  anus 
and  between  the  sphincter  muscles.  In  this  chapter  only 
those  varieties  of  fistula  which  are  amenable  to  treat- 
ment under  local  anesthesia  will  be  discussed,  viz.,  sim- 
ple complete  fistula,  blind  external,  blind  internal  and 
sub-mucous.  (Fig.  71.) 

Simple  Complete  Fistula.  This  is  the  commonest 
form  of  fistula  met  with,  and  is  the  remains  of  a  sub- 
cutaneous or  ischio-rectal  abscess,  and  consists  of  a 
straight  or  slightly  curved  channel  running  from  the  anal 
canal  or  some  point  in  the  rectum  a  little  higher  up,  to  the 
outside  skin — usually  opening  within  one  or  two  inches 
to  one  side  or  the  other,  and  below  the  anal  aperture. 
The  external  opening  may  be  at  any  point  on  the  skin  in 
the  vicinity  of  the  anus,  but  the  points  mentioned  are 
the  most  usual  sites. 

Symptoms. — The  symptoms  are  a  sense  of  irritation  or 
an  itching  of  the  anal  region,  pain  during  defecation,  and 
the  presence  of  a  purulent  discharge.  If  for  any  reason 
one  of  the  openings  should  become  plugged  up,  there  is 
some  distension  and  pain  from  pressure. 

Diagnosis. — The  diagnosis  of  fistula  should  always  be 
in  mind  when  on  examination  of  a  patient  a  papule  is  seen 
on  the  perineum  or  buttocks,  from  which  a  drop  of  pus 
exudes  or  can  be  pressed  out.  This  is  the  characteristic 
appearance  of  the  external  opening  of  a  fistula,  With 


ANO-KECTAL  FISTULAE. 


155 


Fig.  71. 
Ano-Rectal   Fistulae. 

1.  Blind   internal   fistula. 

2.  Blind    external    fistula. 

3.  Complete   direct   fistula. 

4.  Submucous    or    submuco-cutaneous    fistula. 


ll 


156  DIRECT,     COMPLETE     FISTULA DIAGNOSIS. 

the  patient  in  the  lateral  position  and  the  index  finger 
of  one  hand  over  the  external  opening,  the  index  finger 
of  the  other  should  be  inserted  with  the  palmar  surface 
directed  toward  the  posterior  commissure.  Often  by  the 


Fig.  72. 

Direct   Complete   Fistula   in   Ano. 

The  probe  is  seen  entering  the  external  or  cutaneous  opening  while 
directly  above  it  its  blunt  tipped  extremity  is  seen  emerging  from  the 
anus. 

Photograph   of  one  of  author's  cases. 

pressure  with  the  finger  in  the  rectum  a  drop  of  pus  will 
be  forced  out  through  the  external  opening.  By  care- 
fully feeling  the  region  between  the  anal  canal  and  the 
outside  opening,  one  will  often  make  out  the  cord  like 
feel  of  the  fistulous  tract.  Oftentimes  the  internal  open- 
ing is  extremely  difficult  to  find.  Upon  examination  with 
the  author's  fenestrated  anoscope,  or  the  anoscope  with 
the  oblique  aperture,  a  small  reddened  spot  often  raised 
somewhat  from  the  surface  will  be  detected,  from  which 


DIAGNOSIS. 


157 


pus  can  be  squeezed  out.  When  this  point  is  discovered, 
digital  examination  will  reveal  the  induration  underneath 
the  surface,  which  discloses  the  direction  of  the  fistulous 
tract.  If  after  careful  examination  of  the  entire  circum- 
ference of  the  anal  canal  and  lower  rectum,  no  internal 
opening  can  be  detected,  the  injection  into  the  external 
opening  of  peroxide  of  hydrogen,  methylene  blue  solu- 
tion, or  milk  of  magnesia  or  bismuth,  will  assist  one  in 
locating  the  internal  opening  by  the  point  of  appearance 
of  the  solution  inside  the  anus  or  rectum. 


Fig.  73. 
Angular   Fistulous   Tract. 

The  upper  portion  of  the  fistula  has  been  opened  and  the  probe  can 
be  seen  entering  the  lower  portion.  The  end  of  the  probe  can  be  seen 
emerging  from  the  left  upper  quadrant  of  the  anus. 

Photograph   from  one  of  author's  cases. 


158  SIMPLE  DIRECT  FISTULAE — TREATMENT. 

The  probe  may  be  used  to  diagnosticate  the  presence 
and  direction  of  a  fistulous  tract,  but  in  order  to  be  of 
and  value  it  must  be  very  fine  and  extremely  pliable- 
one  made  of  annealed  silver  is  the  best  for  this  purpose. 
One  must  be  extremely  careful  in  introducing  a  probe 
into  a  fistulous  tract,  for  it  is  very  easy  to  force  it  through 
the  walls  of  the  fistula  or  into  the  rectum,  thus  creating 
a  false  passage.  If  the  probe  does  not  pass  easily  it  is 
better  to  discard  it  than  to  use  any  force  in  its  use.  If 
there  is  a  suspicion  that  the  fistula  communicates  with 
the  bladder  or  urethra,  the  injection  of  a  mild  solution 
of  methyl ene  blue  (1-5%)  into  the  organ  will  settle  the 
question.  If  such  a  communication  be  present  the  col- 
ored solution  will  exhibit  itself  at  the  fistulous  opening"" 
in  very  short  order. 

Treatment. — The  treatment  of  fistula  as  a  general  thing 
is  best  accomplished  under  general  anesthesia,  because 
many  times  upon  laying  open,  what  appears  to  be  a  sim- 
ple fistulous  tract,  ramifications  and  extensions  may  be 
found  which  would  necessitate  more  dissection  than  is 
possible  to  satisfactorily  accomplish  under  local  anes- 
thesia. A  case  of  simple,  direct  fistula,  however,  which 
is  not  tortuous,  and  in  which  the  external  and  internal 


Fig.  74. 
Grooved  Director. 

openings,  and  the  line  of  communication  are  made  out 
by  the  diagnostic  methods  mentioned  above,  may  be 
treated  under  local  anesthesia  in  any  one  of  three  ways. 


INCISION TECHNIQUE.  159 

Incision. — Simple  incision  will  suffice  in  some  cases 
where  the  fistula  is  not  deep  seated.  After  the  bowels 
have  been  washed  out  with  a  saturated  boracic  acid  solu- 
tion and  the  area  around  the  anus  scrubbed,  shaved  and 
sterilized,  the  sphincter  is  anesthetized  according  to  the 
technique  outlined  in  Chapter  XV,  and  the  tissues  over 
the  fistula  injected  to  the  point  of  blanching  with  one- 
half  of  1  per  cent  solution  of  eucain.  A  probe-pointed 
grooved  director  is  then  passed  through  the  fistula  from 
the  external  to  the  internal  opening,  and  all  the  tissues 
between  the  director  and  the  surface  divided  by  a  curved 
bistoury  passed  from  without  inward,  thus  freeing  the 
director  and  laying  open  the  entire  fistula.  A  pledget  of 
cotton  soaked  with  4%  solution  of  eucain  is  pressed  into 
the  incision,  and  is  held  firmly  against  the  opened  fistu- 
lous  tract  for  two  or  three  minutes.  It  is  then  removed 
and  the  diseased  surface  lightly  curetted  with  a  sharp 
spoon  curette ;  the  incision  firmly  packed  with  gauze  and 
an  anodyne  suppository  inserted  and  a  dressing  applied. 

Unless  the  direction  of  the  fistulous  tract  is  in  a  line 
at  right  angles  to  the  fibres  of  the  sphincter  muscle,  it 
must  not  be  opened  by  a  single  straight  incision.  It  is 
an  invariable  rule,  that  any  incision  which  must  sever 
any  or  all  the  fibres  of  the  sphincter,  should  cross  it  only 
at  right  angles  (Fig.  75)  in  order  to  prevent  incontinence 
afterwards.  The  incision  therefore  must  be  so  directed 
that  it  never  severs  the  sphincter  muscle  in  an  oblique 
manner.  "Where  the  fistula  is  located  just  below  the  skin 
or  mucous  membrane  and  does  not  involve  the  sphincter, 
this  rule  does  not  necessary  hold  good. 

Excision. — In  some  cases  it  will  be  found  advantageous 
instead  of  simply  opening  the  fistulous  tract,  to  excise 


EXCISION TECHNIQUE. 


the  entire  canal.  This  is  the  most  satisfactory  operation 
when  it  can  be  successfully  carried  out,  and  should  be 
the  operation  of  choice  in  all  straight,  uncomplicated  fis- 


Fig.  75. 
Right  Angled  Incision  for  Simple  Direct  Fistula  in  Ano. 

In  a  simple  fistula  by  which  the  bowel  communicates  with  the  external 
integument,  crossing  the  external  sphincter  in  an  oblique  manner,  the 
external  sphincter  is  cut  at  right  angles  by  the  method  outlined. 

tulae  which  are  situated  so  that  the  tissues  surrounding 
the  fistula  can  be  sucessfully  infiltrated.  After  the  usual 
preparation  of  the  patient  and  anesthetization  and  dilata- 
tion of  the  sphincter  muscles,  the  tissues  surrounding  the 
fistula  are  anesthetized.  One-half  of  1  per  cent  solution 
of  eucain  is  injected  into  the  skin  along  the  line  of  in- 
cision up  to  the  opening  in  the  anal  canal;  then  the  sur- 
rounding tissues  are  distended  with  one-tenth  of  1  per 
cent  solution  of  eucain,  care  being  taken  to  completely 


AUTHOR'S  TECHNIQUE  FOR  EXCISION  OF  FISTULA.      161 


surround  the  fistula  on  all  sides.  A  grooved  director  or 
probe  is  then  inserted  and  the  end,  which  has  been 
brought  through  the  anal  opening,  is  bent  so  that  it  is 


Fig.   76. 
Author's  Technique  for  Removing  Fistulous  Tract  in  toto. 

The  lateral  incisions  are  so  directed  that  a  V-shaped  bed  is  left,  which 
can  occasionally  be  approximated  by  sutures. 

exposed  outside  of  the  anus.  This  brings  the  entire  tract 
into  view.  The  skin  is  then  incised  the  full  length  of  the 
fistula  down  to  the  infiltrated  tissues  surrounding  it,  but 
not  through  them.  (Fig.  76.)  The  incisions  are  then  car- 
ried on  either  side  of  the  infiltrated  fistulous  canal  in  such 
a  way  as  to  free  it  entirely,  and  remove  it  unopened  and 
threaded  on  the  probe.  As  the  incisions  are  carried  around 
the  fistulous  tract,  they  should  be  brought  together  in  a  V- 


162  AFTER  CARE. 

shaped  manner  beneath  it.  After  the  removal  of  the  fis- 
tula, the  wound  should  be  packed  with  gauze,,  the  anodyne 
suppository  inserted  and  dressing  applied. 

In  the  after  care  following  both  excision  and  incision, 
extreme  care  must  be  taken  in  the  daily  dressing  of  the 
wound  to  so  arrange  the  packing  that  it  is  firm  enough 
to  retard  too  rapid  granulation,  and  yet  packed  so  lightly 
as  to  allow  the  wound  to  gradually  come  together.  Es- 
pecial care  must  be  exercised  to  keep  the  skin  and  mu- 
cous membrane  from  dipping  in  or  growing  down  the 
sides  of  the  incision.  If  granulation  does  not  proceed  as 
rapidly  as  it  should,  the  gauze  packing  should  be  soaked 
with  bovinine  daily  before  applying,  or  pure  ichthyol  or 
balsam  peru  should  be  applied  to  the  granulating  sur- 
faces daily.  It  is  not  necessary  or  advisable  to  use  any  of 
the  antiseptic  powders  in  the  after  treatment  of  these 
cases. 

The  bowels  are  not  allowed  to  move  for  three  days, 
after  which  daily  movements  are  not  contra-indicated. 

Where  it  has  been  necessary  to  divide  the  sphincter 
either  in  part  or  in  its  entirety,  there  may  be  some  tem- 
porary lack  of  full  control  of  the  bowel  movements ;  but 
as  the  wound  heals  up,  control  is  regained  so  that  no  fear 
need  be  felt  on  this  score.  The  patient  is  allowed  to  be 
up  and  around  after  the  first  24  hours,  and  can  pursue 
his  usual  occupation  without  much  discomfort. 

Ligature  Operations. — In  some  few  cases  where  either 
from  the  desire  of  the  patient  that  no  cutting  operation 
be  done,  or  some  other  contra-indication,  one  may  occa- 
sionally accomplish  the  cure  of  a  simple  direct  fistula  by 
means  of  a  ligature  either  of  linen,  silk  or  rubber.  The 
author  does  not  advise  the  use  of  the  ligature  in 


LIGATUEE  OPERATION. 


163 


cases,  as  he  personally  feels  that  they  are  never  so  satis 
factory,  and  certainly  not  as  quick  in  their  results  as  a 
clean-cut  surgical  operation  under  local  anesthesia;  If 


A. 


Fig.   77. 

Technique  of  Passing  Flexible  Silver  Probe  Threaded  With  Rub- 
ber Ligature  Through  Simple  Direct  Fistula  in  Ano. 


164  LIGATURE  OPERATION. 

the  patient  must  have  a  ligature  operation,  the  rubber  lig- 
ature as  used  by  the  author  in  his  operation  for  rectal 
valvotomy  is  to  be  advised,  as  it  is  quicker  and  surer  in 
its  results  than  silk  or  linen. 

The  ligature  is  applied  in  the  following  manner:  A 
probe  is  threaded  with  the  material  of  choice  and  it  is 
passed  through  the  fistula  from  without  inward;  the  point 
projecting  in  the  rectum  is  grasped  with  forceps  and  is 
pulled  through  and  outside  of  the  anus.  The  ligature 
if  silk  or  linen,  is  then  loosely  tied  so  as  not  to  constrict 
.  the  parts  but  lightly  surround  them  and thlTends  cut  off. 
This  leaves  a  small  loop  not  unlike  a  seton.  This  is 
moved  to  and  fro  every  day  by  the  patient  and  in  the 
course  of  three  to  six  weeks  gradually  wears  through,  the 
fistula  healing  behind  the  ligature,  as  it  works  through. 
In  some  cases,  however,  this  will  not  prove  efficacious. 

Where  more  quick  action  is  desired  it  is  better  to 
use  the  rubber  ligature.  It  is  passed  through  the  fistula, 
threaded  on  a  probe,  in  the  same  manner  as  the  non-elas- 
tic ligatures,  but  when  it  is  fastened  with  a  perforated 
shot,  it  is  put  on  the  stretch.  This  causes  so  much  pain 
and  suffering  to  the  patient  for  the  first  12  hours  that  it 
is  necessary  to  give  repeated  doses  of  anodynes.  After 
this  period,  however,  there  is  comparatively  no  pain  or 
discomfort  until  the  ligature  sloughs  its  way  through, 
which  occurs  in  the  course  of  from  three  days  to  a  week. 
The  suffering  caused  by  the  use  of  this  rubber  ligature 
is  far  more  intense  than  that  suffered  after  one  of  the 
radical  measures  mentioned  above,  and  the  author  can- 
not conscientiously  recommend  it  except  in  those  cases 
where  other  measures  are  refused  by  the  patient. 

Blind  External  Fistula.    The  blind  external  fistula  is 


BLIND  EXTERNAL  FISTULA. 


Fig.  78. 

B.     Showing  Method  of  Constricting  the  Area  Between  Fistula,  Anal 

Mucous  Membrane  and  Skin  by  Means  of  the  Rubber  Ligature 

Drawn  Taut  and  Fastened  With  a  Perforated  Shot. 

caused  by  the  opening  of  a  peri-anal  abscess  on  the  skin 
surface  only.  It  is  characterized  by  the  appearance,  af- 
ter the  rupture  or  opening  of  an  abscess  in  this  region, 
of  a  red  spot  or  papule  from  which  pus  is  discharging.  It 
is  accompanied  by  discomfort  to  the  patient  when  sit- 
ting; pruritus  ani.  or  disagreeable  moisture  in  the  region, 


166  BLIND  INTERNAL  FISTULA SYMPTOMS. 

and  its  diagnosis  from  complete  fistula  is  made  by  the 
method  of  examination  outlined  above.  In  reality  it  is 
nothing  more  or  less  than  a  contracted  abscess  cavity 
which  refuses  to  heal  on  account  of  the  action  of  the 
sphincter  muscle  in  keeping  it  open. 

The  treatment  consists  in  the  incision  with  curetting 
and  packing,  or  excision  of  the  entire  fistulous  tract. 
Some  authors  advise  the  converting  of  an  external  fistula 
into  a  complete  fistula  and  then  operating  as  for  complete 
fistula.  The  author  cannot  see  the  reason  or  advisability 
of  thus  converting  a  simple  abscess  cavity  into  a  fistula, 
and  would  strongly  deprecate  any  such  methods.  The 
author  does  not  believe,  in  fact,  knows  that  it  is  not  nec- 
essary to  divide  the  sphincter  in  order  to  heal  a  blind  ex- 
ternal fistula. 

Blind  Internal  Fistula.  This  variety  of  fistula  is  char- 
acterized by  its  having  an  opening  into  the  bowel  only, 
and  is  caused  by  the  rupture  into  the  bowel  of  a  peri- 
rectal  abscess  whose  point  of  least  resistance  was  to- 
wards the  rectum.  They  are  characterized  by  their  in- 
sidious and  obscure  onset  and  often  go  for  some  time 
undiagnosed. 

Symptoms. — The  chief  symptom  is  the  appearance  of 
a  purulent  discharge  from  the  anus.  This  is  accompanied 
by  some  smarting,  burning,  or  itching  and  a  feeling  of 
unrest  or  discomfort  in  the  lower  rectum.  If  there  is 
much  involvement  of  the  mucous  membrane  surrounding 
this  opening  there  is  also  a  tendency  to  diarrhoea.  When 
a  patient  has  complained  of  pain  in  the  rectum  persisting 
for  several  days,  accompanied  by  heat,  throbbing,  and 
rise  of  temperature ;  and  these  symptoms  are  more  or  less 
relieved  just  previous  to  the  passage  of  a  quantity  of  pus 


BLIND  INTERNAL  FISTULA DIAGNOSIS TREATMENT.      167 

from  the  anus — the  breaking  of  a  sub-mucous  or  peri-rec- 
tal abscess  into  the  rectum  should  be  suspected.  The 
continuance  of  a  purulent  discharge  off  and  on  for  a  pe- 
riod of  weeks  and  months,  means  the  existence  of  a  blind 
internal  fistula. 

Diagnosis. — With  the  patient  either  in  the  lithotomy 
or  lateral  position,  a  roughened  spot  with  indurated  edges 
is  felt  on  digital  examination,  usually  posteriorly  or  lat- 
erally. Upon  stroking  or  milking  the  interior  of  the  rec- 
tum adjacent  to  this  opening,  a  purulent  discharge  will 
be  produced.  Upon  examination  through  the  anoscope  or 
fenestrated  speculum  the  opening  will  be  seen  usually 
within  the  first  inch  from  the  anal  margin.  It  will  be 
dark  red  in  color,  with  edges  somewhat  raised  and  the 
extent  of  the  fistula  can  be  readily  determined  by  exam- 
ination with  a  soft  silver  probe.  It  is  well  to  bend  the 
probe  on  itself  in  the  form  of  a  hook,  so  as  to  determine 
the  extent  of  excavation  under  the  mucous  membrane  of 
the  bowel  in  the  direction  of  the  anus,  as  not  infrequently 
blind  internal  abscesses,  particularly  of  the  submucous 
variety,  are  found  with  their  largest  cavity  extending 
down  towards  the  anus.  The  blind  internal  fistula  is  more 
frequently  the  result  of  a  submucous  abscess  than  of  any 
other  variety,  and  its  channel  very  rarely  penetrates  the 
muscular  coat  of  the  rectum. 

Treatment. — With  the  patient  either  in  the  lithotomy 
or  lateral  position  and  the  external  parts  washed,  shaved 
and  sterilized,  the  sphincter  ani  muscle  is  anesthetized 
and  dilated  according  to  the  technique  described  in  Chap- 
ter XV.  Either  a  De  Vilbiss  rectal  speculum  or  the  ano- 
scope with  the  opening  on  the  slant  is  inserted  so  as  to 
best  expose  the  opening  of  the  fistula.  Its  direction  and 


168          BLIND    INTERNAL    FISTULA SUBMUCOUS    TRACT. 

extent  having  been  determined,  the  tissues  over  the  ab- 
scess and  surrounding  it  are  infiltrated  with  one-tenth 
of  one  per  cent  solution  of  eucain.  A  grooved  director 
is  then  inserted  and  the  fistula  is  laid  open  with  a  long- 
handled  scalpel  or  the  author's  angular  rectal  scissors. 
A  pledget  of  absorbent  cotton  soaked  with  4%  solution 
of  eucain  is  then  placed  in  the  abscess  cavity  and  allowed 
to  remain  for  two  or  three  minutes.  The  interior  of  the 
tract  is  lightly  curetted  and  a  strip  of  sterile  gauze  in- 
serted for  drainage,  one  end  of  the  gauze  being  carried 
outside  of  the  anus.  In  laying  the  tract  open,  the  lower 
extremity  should  be  opened  well  down  to  the  anus,  care 
being  taken  to  leave  no  pockets  at  the  lower  epd.  In  24 
hours  the  gauze  is  removed  and  a  cleansing  enema  given. 
The  bowel  should  be  allowed  to  move  on  the  third  day, 
the  stools  being  softened  by  the  administration  of  liquid 
albolene,  and  they  should  be  kept  moving  regularly  each 
day.  Ordinarily  these  cases  will  heal  without  any  fur- 
ther attention.  It  is  well,  however,  to  have  the  patient 
report  every  other  day  for  a  week  or  so  and  to  make  sure 
that  the  cavity  is  kept  healing  from  the  bottom  and  the 
granulations  healthy. 

Submucous  Tract.  There  is  a  variety  of  submucous 
fistula  extending  usually  from  the  bottom  of  a  crypt 
of  Morgagni  which  has  been  called  by  Wallis.  a  submu- 
cous tract.  It  consists  in  nothing  more  or  less  than  either 
an  unusually  small  calibered  submucous  fistula,  or  a  very 
deep  inflamed  crypt.  It  gives  rise  to  an  irritating  puru- 
lent discharge  which  is  very  small  in  amount,  but  which 
sometimes  is  responsible  for  the  production  of  pruritus 
ani.  In  order  to  determine  its  presence,  it  is  advisable 
in  those  cases  where  a  discharge  is  noted  and  no  internal 


SUBMUCOUS   FISTULA— BISMUTH   PASTE.  169 

opening  of  a  blind  fistula  can  be  found,  to  examine  with 
a  probe  each  of  the  Morgagnian  crypts  and  determine  the 
presence  or  absence  of  one  of  these  so-called  submucous 
tracts.  If  present,  it  can  be  slit  up  with  a  sharp  pointed 
bistoury-  after  anesthetizing  as  outlined  above.  It  re- 
quires no  after-treatment  other  than  examination  every 
other  day  for  three  or  four  days,  to  make  sure  that  it  does 
not  heal  over  at  the  surface  before  it  is  thoroughly  healed 
underneath. 

Submucous  or  Muco- Cutaneous  Fistula.  Cripps  de- 
scribes a  variety  of  fistula  very  similar  to  the  submucous 
tract  which  he  calls  muco-cutaneous  fistula.  It  differs 
from  the  variety  just  described  only  from  the  fact  that 
it  communicates  with  the  surface  through  a  small  open-, 
ing  in  one  of  the  anal  folds  instead  of  one  of  the  crypts 
of  Morgagni.  (Fig.  71,4.) 

The  treatment  of  this  variety  is  just  the  same  as  that 
just  preceding  and  need  not  be  described  in  detail. 

The  Injection  of  Bismuth  Paste.  The  use  of  a  mix- 
ture of  bismuth  subnitrate  and  vaseline  in  the  diagnosis 
and  treatment  of  fistulous  tracts,  sinuses  and  abscess 
cavities,  first  brought  out  by  Emil  G.  Beck,  of  Chicago, 
has  opened  up  an  interesting  field  in  the  non-operative 
treatment  of  ano-rectal  fistulae.  Pennington,  in  a  recent 
article  on  the  subject  in  the  Lancet-Clinic,  December  26, 
1908,  reports  17  cases  treated  by  this  method.  The  paste 
used  by  Pennington  consisted  of  bismuth  subnitrate  1 
part  and  vaseline  2  parts.  To  stiffen  the  paste  from  5 
to  10 %  each  of  white  wax  and  soft  paraffine  are  added. 
The  technique  is  as  follows: 

The  patient's  bowels  are  thoroughly  washed  out  and 
the  fistulous  tract  irrigated  as  well  as  possible.  An  olive 


170  INJECTION  OF  BISMUTH  PASTE. 

* 

pointed  glass  syringe  with  asbestos  packing  around  the 
plunger  is  filled  with  the  mixture,  which  has  previously 
been  sterilized  and  allowed  to  cool  to  a  temperature  that 
will  not  irritate  the  patient.  The  point  of  the  springe  is 
pressed  well  into  the  main  opening  of  the  fistula,  if  more 
than  one  exists,  and  the  paste  slowly  injected.  Should 
there  be  an  internal  opening  or  communication  with  the 
bowel,  the  finger  of  the  hand  not  manipulating  the  syringe 
is  inserted  into  the  rectum  to  close  that  opening,  thus  pre- 
venting the  paste  entering  the  bowel  and  aiding  in  forc- 
ing it  into  all  the  diverticuli  and  tortuous  tracts.  The 
same  precaution  is  observed  where  there  is  more  than 
one  external  communicating  opening.  The  syringe  is  not 
removed  as  soon  as  the  tracts  seem  to  be  filled,  but  is  held 
firmly  in  position  with  slight  continuous  pressure  on  the 
piston.  The  finger  in  the  rectum  is  also  held  in  position 
until  the  material  has  hardened,  when  it  may  be  with- 
drawn and  the  syringe  removed.  A  gauze  dressing  and 
T-bandage  are  then  applied.  From  one  to  five  injections 
suffice  for  the  average  case,  and  they  should  be  given  ei- 
ther once  or  twice  a  week.  Pennington's  cases  required 
from  2  to  6  weeks  for  a  cure.  While  he  states  that  this 
method  does  not  supplant  the  radical  cure  of  fistula  by 
operation  he  feels  that  it  should  be  thoroughly  tried  in 
all  cases  before  operative  procedures  are  undertaken,  for 
these  reasons : 

1.  It  may  cure  the  case.  2.  On  account  of  the  aversion 
of  most  patients  to  a  surgical  operation.  3.  On  account 
of  the  failure  now  and  then  of  the  occasional  operator  to 
cure  his  patient.  4.  On  account  of  the  fear  of  the  loss 
of  control  over  the  bowels.  5.  For  its  cosmetic  effect, 
there  being  no  scars  or  irregularities  left  as  after  surgi- 


FISTULA  I]ST  ANO  IN  THE  TUBERCULOUS.  171 

cal  operations.  6.  Because  it  is  often  impossible  to  tell 
the  extent  of  the  fistula  until  after  the  operation  is  begun. 
7.  If  this  method  should  fail,  there  always  remains  the 
various  surgical  procedures. 

Fistula  in  Ano  in  the  Tuberculous  Patient.  The  only 
reason  that  the  discussion  of  fistula  in  ano  in  a  tubercu- 
lous patient  is  taken  up  among  these  varieties  of  fistula 
which  can  be  treated  under  local  anesthesia,  is  the  fact 
that  the  tuberculous  patient  is  a  very  poor  subject  for 
general  anesthesia.  The  apparent  connection  between 
fistula  in  ano  and  tuberculosis  is  due  to  the  fact  of  the 
tubercular  patient's  resisting  powers  being  away  below 
par.  Abscesses  in  the  ano-rectal  region  tend  to  fistula 
formation  frequently  enough  in  those  individuals  who 
have  a  normal  resisting  power;  therefore  it  stands  to 
reason  that  this  should  be  more  so  in  those  suffering  from 
any  of  the  wasting  diseases  and  particularly  the  most 
common  one,  tuberculosis.  The  tubercular  patient's  in- 
testinal tract  is  constantly  flooded  with  tubercular  bacilli 
and  an  abscess  cavity  communicating  with  the  gut  forms 
a  convenient  location  for  them  to  locate  and  propagate. 
The  old  idea  that  the  operation  for  tuberculous  fistula  has 
any  bad  influence  on  the  patient's  pulmonary  condition 
is  absolutely  untenable.  As  a  matter  of  fact,  the  local 
symptoms  and  inconvenience  caused  by  the  fistula  make 
the  patient  much  more  irritable  and  adds  to  his  already 
overwhelming  burden. 

Symptoms. — The  symptoms  are  those  accompanying 
fistula  in  ano  as  described  above,  the  constitutional  symp- 
toms of  tuberculosis  being  also  present. 

Diagnosis. — The  only  point  of  difference  between  fist- 
ula in  ano  complicated  with  tuberculosis  and  ordinary 

12 


172  TUBERCULOUS  FISTULA TREATMENT. 

fistula  is  the  presence  in  the  discharge  of  the  bacillus  tu- 
berculosis, and  the  pink,  flabby  looking,  unhealthy,  granu- 
lations found  around  the  external  opening.  There  is  also 
a  tendency  to  undermining  of  the  skin  edges. 

Treatment. — The  treatment  of  a  tuberculous  fistula  is 
the  same  as  that  outlined  above  for  the  different  van 
eties  of  ordinary  fistula  in  ano,  with  the  exception  that 
when  the  fistulous  tract  is  laid  open  after  lightly  curet- 
ting, its  inner  surface  is  swabbed  with  pure  lactic  or  gla- 
cial acetic  acid.  lodoform  or  iodosyl  gauze  is  used  for 
packing  and  dressing  on  account  of  the  peculiarly  antag- 
onistic effect  of  iodine  to  the  tubercle  bacillus.  The  pa- 
tient should  be  encouraged  to  live  an  out  of  door  life,  and 
his  general  bodily  nutrition  and  physical  condition 
looked  after  the  same  as  any  other  tubercular  patient. 


CHAPTER  X. 


HEMORRHOIDS. 

Hemorrhoids,  which  is  the  most  common  disease  of  the 
ano-rectal  region  presenting  a  pathological  change  in  the 
tissues,  is  also  the  most  frequently  self-treated  condition 
affecting  this  region.  We  see  more  quack  advertisements, 
more  nostrum  remedies  presented  for,  more  irregular 
practitioners  holding  themselves  out  to  cure  hemorrhoids, 
than  any  other  disease  (with  the  possible  exception  of 
venereal  disease).  In  many  quarters  intelligent  people, 
who  would  not  think  of  consulting  an  unethical  practi- 
tioner for  any  other  condition,  will  consult  the  so-called 
"pile  specialist" — who  holds  himself  forth  in  the  daily 
press — because  they  believe  that  members  of  the  regular 
profession  do  not  treat  rectal  diseases.  It  is  perfectly 
astonishing  to  what  an  extent  this  belief  is  held;  in  fact, 
the  author  is  sorry  to  say  that  he  knows  of  instances 
where  members  of  our  profession,  in  good  standing,  have 
referred  cases  of  rectal  disease  to  advertising,  so-called 
rectal  specialists. 

There  must  be  a  reason  for  this,  and  that  reason  is  the 
lack  of  instruction  to  the  medical  student  on  the  subject 
of  rectal  disease,  in  the  first  place;  the  paucity  of  such 
instruction  when  given  as  an  incident  in  the  teaching  of 
general  surgery;  the  repugnance  with  which  the  average 

173 


174   NEGLECT  OF  PROCTOLOGY  BY  GENERAL  PROFESSION. 

practitioner  approaches  a  case  requiring  rectal  examina- 
tion; the  cursory  character  of  such  examination;  the  dis- 
taste of  the  average  practitioner  for  local  treatment  of 
the  ano-rectal  region ;  the  inability  to  make  a  correct  diag- 
nosis; and  the  superficial  treatment  given  and  the  early 
discharge  of  the  patient  by  the  practitioner,  who  is  anx- 
ious to  get  rid  of  a  case,  which  is  unpleasant  for  him  to 
treat — all  are  responsible  for  the  position  which  the  av- 
erage general  practitioner  occupies  today  in  the  diag- 
nosis and  treatment  of  rectal  diseases. 

It  is  the  action  of  the  profession  itself  which  has  cre- 
ated the  special  field  of  proctology — the  anus  and  rectum 
being  organs  peculiar  to  themselves  and  being  subject  to 
many  medical  and  surgical  diseases  in  the  same  way  as 
the  eye,  the  ear,  the  nose,  the  genital  and  urinary 
organs ;  and  call  for  just  as  much  special  medical  as 
for  surgical  care.  The  general  surgeon  knows  nothing 
about,  and  cares  less  for,  the  medical  treatment  of  these 
organs ;  and  the  general  practitioner  who  is  able  to  treat 
the  medical  conditions  is  not,  as  a  rule,  properly  equipped 
to  do  so.  Thus,  the  proctologist  came  into  existence- — a 
man  who,  by  special  study  of  this  particular  region  of  the 
body,  is  able  to  give  special  care  of  either  a  surgical  or 
medical  nature,  and  often  both  in  the  same  case,  as  may 
be  required.  With  his  attention  directed  particularly  to 
this  line  of  work,  his  operative  measures  are  directed 
largely  along  the  lines  of  conservatism.  He  endeavors  to 
save  as  much  tissue  as  he  can  and  cut  as  little  as  he  can, 
and  by  intelligent  after-care  to  promote  healing  much 
more  near  the  normal  as  a  rule  than  does  the  man  who 
"cuts  a  fistula  and  ties  a  pile"  and  lets  it  go  at  that. 

That  the  average  general  practitioner  is  fully  as  capa- 


HEMORRHOIDS CLASSIFICATION.  175 

ble  to  treat  many  ano-rectal  diseases,  as  the  proctologist ; 
if  he  has  at  his  hand  a  practical  work  outlining  indicated 
therapeutic  measures  in  a  plain,  simple  way;  goes  with- 
out saying. 

The  treatment  of  hemorrhoids  in  the  hands  of  the  prac- 
titioner has  undergone  vast  changes  since  special  atten- 
tion has  been  directed  along  this  line.  In  many  ways  it 
has  been  much  simplified,  and  the  results  have  been  ex- 
tremely satisfactory. 

Varieties.  Hemorrhoids  are  tumors  or  swellings  pro- 
duced by  pathologic  changes  in  the  veins  of  the  anus  and 
rectum,  accompanied  by  more  or  less  infiltration  of  the 
surrounding  tissues  and  hypertrophy  of  the  anal  skin. 
They  are  usually  divided  into  three  classes,  according  to 
location:  External,  internal,  and  externo-internal.  The 
external  being  those  outside  of  the  sphincterial  region  and 
covered  by  integument;  the  internal  being  covered  with 
mucous  membrane,  and  whether  situated  inside  of  the 
bowel  or  prolapsed  outside ;  they  are  nevertheless  inter- 
nal. An  internal  hemorrhoid  being  prolapsed  and  remain- 
ing prolapsed  may  appear  externally,  but  if  it  is  covered 
by  mucous  membrane  it  is  an  internal  hemorrhoid.  The 
externo-internal  variety  is  a  combination  of  the  two  pre- 
ceding, being  covered  by  both  mucous  membrane  and  skin. 
The  external,  again,  are  divided  into  thrombotic,  integu- 
mentary and  varicose. 

The  thrombotic  variety  usually  appears  suddenly ;  may 
range  in  size  from  a  pea  to  a  large  grape ;  is  rounded,  of 
a  bluish,  purplish  hue,  and  extremely  painful.  It  feels 
much  larger  to  the  patient  than  it  really  is,  and  is  charac- 
terized by  its  sudden  onset.  The  integumentary  variety 
is  a  sac  or  pouch  of  thickened  skin,  usually  the  remains  of 


176 


HEMOERHOIDS — CLASSIFICATION. 


.       Fig.  79. 
Acute   External  Thrombotic   Hemorrhoid. 

These   are    characterized   by   their   sudden    onset   and   are   of   a   bluish 
or  purplish  hue. 

Drawing   from   photograph   of   one   of   author's   cases. 

an  old  acute  thrombofic  hemorrhoid  which  has  undergone 
absorption.  The  varicose  variety  consists  of  a  collection 
of  small  varicose  veins  covered  by  skin  and-  situated  at 
or  outside  of  the  anal  orifice. 

The  internal  variety  are  divided  into  the  capil- 
lary or  granular,  and  the  varicose.  The  capillary 
hemorrhoid  may  not  appear  as  a  tumor  at  all, 
but  simply  a  circumscribed  reddened  area  which  bleeds 
upon  touch.  Where  there  is  an  enlargement,  it 


HEMOKRHOIDS ETIOLOGY.  177 

looks  not  unlike  a  raspberry.  Its  color  is  brighter  than 
the  varicose  variety  and  it  bleeds  more  freely.  The  vari- 
cose internal  hemorrhoid  is  caused  by  a  varicosity  of  the 
veins  of  the  superior  hemorrhoidal  plexus,  the  varicose 
veins,  together  with  the  infiltrated  skin  surrounding  them, 
forming  rounded  tumors  of  varying  sizes.  The  internal 
hemorrhoids  may  also  be  divided  into  pedicled  and  ses- 
sile, either  of  which  variety  may  protrude  through  the 
anus. 


Fig.  80. 
External  Thrombotic  Hemorrhoids. 

This  specimen,  removed  from  one  of  the  author's  cases,  illustrates 
the  thrombotic  nature  of  the  condition.  There  were  four  distinct  clots 
present  in  this  case,  and  they  were  removed  en  masse. 

Causes.  A  great  many  different  causes  have  been  as- 
signed for  hemorrhoids.  The  principal  predisposing  cause 
is  the  erect  position  which  man  assumes,  and  the  lack  of 
valves  in  the  rectal  veins,  causing  the  weight  of  the  column 
of  blood  to  rest  on  the  veins  of  the  lower  rectum  and 
anus.  Anything  which  will  abnormally  increase  this 
weight  or  the  pressure  on  the  vein  wall  will,  of  course, 


178 


ETIOLOGY. 


Fig.   81. 

External  Cutaneous  Hemorrhoids. 
Drawn   from  one  of  the  author's   cases   suffering   from   tertiary    syphilis. 

cause  dilatation  and  enlargement.  Constipation  is  an 
occasional  cause  of  hemorrhoids.  The  large,  hard  stool, 
as  it  is  passed  down  through  the  rectum,  pushing  the 
blood  ahead  of  it,  and  milking  the  veins,  as  it  were,  caus- 
ing unusual  pressure  in  the  lower  portions 'of  the  hemor- 
rhoidal  plexus  at  the  anal  canal.  A  more  common  cause, 
however,  than  constipation  is  the  effort  to  relieve  consti- 
pation by  means  of  purgatives;  the  unnatural  straining 
and  the  irritating  liquid  stools  being  responsible  for  more 
cases  of  hemorrhoids  than  constipation  itself.  Over-eat- 
ing and  lack  of  exercise,  or  anything  which  causes  a  con- 


ETIOLOGY. 


179 


gestion  of  the  portal  circulation  are  important  causative 
factors  in  their  production.  Occupation  enters  largely 
into  their  etiology.  Men  who  are  on  their  feet  continu- 
ally, such  as  policemen,  letter-carriers,  pedestrians,  rail- 
road men,  travelling  men — are  all  peculiarly  subject  to 
hemorrhoids.  Men  are  more  often  treated  for  hemor- 
rhoids than  women,  not  so  much  because  they  are  more 
subject  to  hemorrhoids,  but  because  women  are  treated 
for  many  gynecological  conditions,  the  relief  of  which 
relieves  the  hemorrhoids.  Many  women  who  suffer  from 
hemorrhoids  caused  by  the  pressure  of  the  pregnant 
uterus  will  be  spontaneously  cured  after  delivery. 


Fig.  82. 

Interne-External    Hemorrhoids. 

Drawn   from   one   of   author's   cases. 


180 


HEMORRHOIDS SYMPTOMS. 


The  most  common  cause,  however,  is  in  the  opinion  of 
the  writer,  the  abuse  of  the  cathartic  habit. 

Symptoms. — The  three  principal  symptoms  associ- 
ated with  internal  hemorrhoids  are  bleeding,  pain  and 
prolapse. 

The  bleeding  is  of  especial  interest.  Many  patients 
suffering  from  hemorrhoids  scarcely  ever,  if  at  all,  pre- 
sent the  symptom  of  hemorrhage.  In  those  cases  the  mu- 
cous membrane  covering  the  hemorrhoid  (and  we  are 
speaking  of  the  internal  hemorrhoid  at  this  time)  is  thick 
and  is  not  easily  ruptured,  and  the  hemorrhoids  may  pro- 


Fig.  83. 
Section  of  Interne-External  Pile. 

(Photo-micrograph,    X4.) 

Upon  the  right  hand  side  of  the  illustration  the  upper  half  has  a  cov- 
ering of  mucous  membrane,  the  lower  half  a  covering  of  skin,  between 
these  there  is  a  sulcus  which  corresponds  with  the  pectinate  line.  The 
upper  half  is  therefore  internal  pile,  the  lower,  external  pile.  The 
structure  of  the  interior  of  both  portions  is  practically  identical — loose 
areolar  tissue  with  dilated  thrombosed  veins. 

The   Rectum:    Its   Diseases  and  Developmental   Defects. 
By   Sir  Charles   Ball. 


THE  SYMPTOM,  BLEEDING.  181 

trude  without  hemorrhage.  Where  bleeding  is  observed, 
it  may  be  very  slight,  consisting  of  a  few  drops  following 
the  stool,  or  is  simply  noticed  on  the  toilet  paper  after 
stool.  In  other  cases  it  is  very  profuse,  several  ounces 
being  lost  with  each  stool,  and  some  patients  have  become 
profoundly  anemic  from  this  cause  alone.  I  might  men- 
tion in  passing  that  it  is  extremely  important  in  every 
case  of  anemia  to  inquire  as  to  whether  the  patient  is 
suffering  from  hemorrhoids  or  not;  as  not  infrequently 
the  rectal  hemorrhage  will  be  found  to  be  the  cause  of 
the  trouble,  and  its  relief  will  be  followed  by  a  prompt 
return  of  the  normal  amount  and  quality  of  blood.  The 
writer  has  observed  in  anoscopic  examination  typical  nr- 
terial  spurting  from  the  midst  of  a  hemorrhoidal  mass. 

Before  leaving  the  subject  of  bleeding  from  hemor- 
rhoids the  author  wishes  to  utter  a  word  of  caution  about 
making  a  diagnosis  of  hemorrhoids  from  the  symptom  of 
rectal  hemorrhage  alone.  Many  a  poor  unfortunate  has 
gone  to  an  untimely  end  because  commencing  malignant 
disease  was  erroneously  diagnosed  as  hemorrhoids  be- 
cause of  the  symptom  of  bleeding  alone.  It  makes  no  dif- 
ference as  to  the  age  of  the  patient,  or  whether  there  is 
pain  present  or  absent,  the  symptom  of  hemorrhage 
should  never  be  taken  for  granted  as  denoting  the  pres- 
ence of  hemorrhoids ;  and  even  where  hemorrhoids  are  ob- 
served, no  man  should  be  satisfied  that  he  has  made  a 
correct  diagnosis  until  he  has  made  a  proctoscopic  exami- 
nation (which  must  include  the  upper  rectum  and  sig- 
moid)  and  the  presence  of  commencing  malignant  disease 
has  been  absolutely  excluded. 

It  is  not  the  intention  of  the  author  in  this  work  to 
cite  cases,  but  he  could  cite  several  seen  in  consultation 


182 


THE   SYMPTOM,  PAIN. 


Fig.  84. 

Interne-External   Hemorrhoid   Injected   With    Anesthetic    Solution 
Ready  to  Operate. 

where  the  diagnosis  of  malignant  disease  was  made  too 
late  to  save  the  patient's  life,  because  the  patient  had  been 
allowed  to  go  for  months—being  treated  for  hemorrhoids 
without  ever  having  had  a  rectal  examination  made.  He 
has  also  seen  numerous  cases  of  fissure-in-ano  diagnosed 
as  hemorrhoids  simply  from  the  appearance  of  blood  fol- 
lowing stool. 

The  pain  of  internal  hemorrhoids  is  somewhat  charac- 
teristic, but  not  pathognomonic.  It  is  more  a  dull  aching 
sensation  accompanied  by  a  feeling  of  fullness  with  or 
without  throbbing.  It  is  seldom  of  an  acute  nature.  The 
patient  complains  of  a  constant  sense  of  weight  and  drag- 
ging in  the  rectum  and  in  the  sacral  region,  and  is  usually 
more  or  less  mentally  depressed.  Many  patients  having 
hemorrhoids  suffer  from  no  pains  whatever. 

The  pain  accompanying  the  acute  thrombotic  pile  is 


THE   SYMPTOM,  PAIN. 


183 


sudden,  lancinating  in  character,  and  is  accompanied  by 
the  appearance  of  the  tumor.  The  pain  soon  becomes  of 
an  intense,  throbbing  character,  and  the  relief  given  upon 
the  incision  of  the  hemorrhoid  and  removal  of  the  clot,  has 
to  be  seen  or  experienced  to  be  appreciated.  The  other 
varieties  of  external  hemorrhoids  are  not  accompanied  by 
pain  at  all,  but  may  be  accompanied  by  considerable  pru- 
ritus. 


Fig.  85. 
Prolapsing  Internal  Hemorrhoids. 

Drawn  from  a  photograph  of  one  of  the  author's  cases. 
This  illustrates  the  extent  to  which  internal  hemorrhoids  may  pro- 
lapse. This  case  was  of  20  years'  standing  and  unless  the  hemorrhoids 
were  prolapsed  after  stool  there  was  nothing  to  distinguish  the  external 
appearance  of  the  anus  in  this  case  from  the  normal.  A  case  of  this 
severity  would  of  course  be  suitable  for  treatment  only  under  general 
anesthesia. 


184  HEMORRHOIDS DIAGNOSIS. 

In  those  cases  of  internal  hemorrhoids  which  prolapse, 
the  prolapse  is  slight  at  first,  gradually  increasing  with 
time.  At  first  the  prolapse  is  replaced  readily  by  the  pa- 
tient after  stool,  but  as  time  goes  on  and  the  prolapse  be- 
comes aggravated,  it  will  come  down  not  only  with  the 
stool  but  when  the  patient  is  up  and  about  and  walking. 
It  finally  remains  down  and  can  only  be  replaced  when  the 
patient  is  lying  down,  or  in  the  knee-shoulder  position, 
and  even  when  held  by  pads  or  retaining  devices  soon 
slips  out  again,  when  the  patient  resumes  the  erect  pos- 
ture and  starts  to  walk. 

Diagnosis.  One  would  think  that  the  mention  of  the 
diagnosis  of  hemorrhoids  would  be  superfluous,  and  that 
the  condition  almost  diagnoses  itself ;  but  it  is  because  of 
the  many  unfortunate  erroneous  diagnoses  of  other  con- 
ditions for  hemorrhoids,  that  the  author  wishes  to  dwell 
somewhat  upon  this  point. 

In  the  first  place,  the  average  patient,  when  consulting 
a  physician  for  suspected  hemorrhoidal  or  other  rectal 
troubles,  is  asked  to  stand  in  front  of  a  table  (see  Fig. 
15)  and  bend  over  on  it  for  a  ''rectal  examination,"  and 
the  physician  inserts  his  index  finger  as  far  as  the  patient 
will  allow  him,  and  that  is  all ;  or,  he  may  take  a  bivalve 
rectal  speculum  (Fig.  35),  and,  if  he  succeeds  in  inserting 
it  far  enough,  will  proceed  to  dilate.  Usually  before  he 
has  gone  very  far,  the  patient  is  off  the  table  and  refuses 
to  allow  a  repetition  of  the  attempt,  and  that  is  about  as 
far  as  the  average  rectal  examination  goes. 

Now  a  complete  examination  (see  Chapter  III)  of  not 
only  the  rectum,  but  the  lower  sigmoidal  cavity  as  well, 
may  be  accomplished,  practically  without  pain,  and  with- 
out any  dilating  speculum.  Cylindrical  proctoscopes  of 


BECTAL  EXAMINATION.  185 

various  lengths  are  used,  and  through  them  everything 
from  the  anal  orifice  to  the  lower  sigmoidal  cavity  can  be 
examined  ocularly  and  an  absolutely  correct  view  of  the 
actual  condition  obtained. 

In  making  an  examination  for  hemorrhoids,  first  ask 
your  patient  to  lie  upon  the  table  in  either  the  right  or 
left  Sim's  position  according  to  the  personal  preference 
of  the  examiner.  "With  the  finger  protected  by  a  thin  rub- 
ber finger  cot,  and  properly  lubricated,  you  proceed  as 
follows : 

After  making  a  careful  inspection  of  the  anus  and  sur- 
rounding tissues,  press  the  point  of  the  finger  against  the 
anus,  asking  the  patient  to  gently  bear  down  as  if  he  were 
trying  to  force  the  finger  out.  The  palmar  surface  of 
the  finger  should  be  towards  the  posterior  commissure  of 
the  anus.  Allow  the  finger  to  slowly  enter  until  you 
have  entered  the  lower  rectal  cavity ;  then,  slowly  turning 
your  finger  from  side  to  side,  note  the  conditions.  As 
the  finger  is  being  withdrawn,  it  should  be  swept  around 
slowly,  taking  note  of  the  absence  or  presence  of  protru- 
sions or  abrasions,  depressions,  elevations — in  fact  every- 
thing which  does  not  feel  like  the  normal  velvety  smooth- 
ness of  the  anal  canal.  An  important  thing  to  remember 
is  not  to  try  to  feel  too  high.  These  conditions  will  all  be 
found  within  the  first  two  or  two  and  one-half  inches,  and 
if  one  does  not  insert  the  finger  too  far,  he  will  be  able 
to  detect  a  great  many  things  in  this  small  area.  One 
must  remember  that  hemorrhoids  of  considerable  size 
may  not  present  any  unusual  feeling  to  the  examining 
finger,  because  of  the  pressure  of  the  finger  emptying 
them  of  blood,  and  they  are  more  or  less  effaced  at  the 
time.  However,  one  can  become  sufficiently  expert,  so 


]86  RECTAL  EXAMINATION. 

that  he  can  detect  the  presence  of  even  these  soft  eleva- 
tions, and  will  note  the  furrows  between  them. 

If  the  presence  of  hemorrhoids  is  accompanied  by  a 
painful  fissure,  one  may  not  be  able  to  insert  the  finger 
without  the  use  of  a  local  anesthetic;  the  technique  of 
which  will  be  found  in  Chapter  XV.  After  digital  exami 
nation  has  been  completed,  an  anoscope  is  introduced, 
the  obturator  withdrawn,  and  the  patient  asked  to  bear 
down.  This  will  prolapse  hemorrhoids  into  the  instru- 
ment, where  they  can  be  examined  without  any  difficulty, 
or  have  the  patient  assume  the  squatting  position  and 
"strain"  the  hemorrhoids  out.  Then  introduce  the  proc- 
toscope, and  following  this  the  sigmoidoscope.  In  intro- 
ducing the  proctoscope,  however,  one  must  employ  the 
knee-shoulder  position.  It  is  in  this  position  only,  that 
satisfactory  dilatation  of  the  rectal  cavity  by  pressure  of 
the  atmospheric  air  can  be  obtained.  The  folds  and 
creases  are  all  smoothed  out  and  every  portion  of  the  rec- 
tal lining  mucous  membrane  can  be  explored  with  the 
eye ;  the  size  and  condition  of  the  rectal  valves  can  be  de- 
termined, and  the  presence  or  absence  of  ulcers  of  the 
rectal  wall  as  well.  The  sigmoidoscope  is  entered  in  this 
position  or  the  exaggerated  lithotomy  position,  and  hav- 
ing an  obturator  the  end  of  which  can  be  turned  at  an 
angle,  it  can  enter  the  recto-sigmoidal  curve  without  dif- 
ficulty. 

Thus  it  will  be  seen  that  this  entire  region  can  be  suc- 
cessfully and  completely  examined  without  using  an  in- 
strument which  will  dilate  the  sphincter  any  more 
than  the  base  of  one's  index  finger.  No  dilatation  is  re- 
quired and  no  pain  is  experienced  by  the  patient.  Of 
course,  during  the  examination  it  may  be  required  to 


DIFFERENTIAL,   DIAGNOSIS.  187 

swab  out  or  douche  out  the  rectum,  all  of  which  can  be 
readily  done  through  the  instruments  mentioned. 

In  the  differential  diagnosis  between  hemorrhoids  and 
other  conditions,  which  may-simulate  some  of  their  symp- 
toms, one  might  mention  first,  fissure.  Fissure  of  the 
anus,  which  may  accompany  hemorrhoids,  is  more  often 
found  alone.  The  pain  of  fissure  is  almost  diagnostic ;  it 
is  sharp,  cutting,  most  intense  during  the  passage  of  a 
stool.  It  remains  often  for  several  hours  following  stool, 
and  is  accompanied  by  more  or  less  tenesmus  and  spasm 
of  the  sphincter  muscle.  The  bleeding  of  fissure  always 
accompanies  or  follows  the  stool.  It  may  consist  merely 
of  a  blood  streak  on  the  stool  or  several  drops  of  blood 
following  the  stool,  or  it  may  merely  be  a  spot  or  smear  on 
the  toilet  paper.  The  presence  of  a  fissure  causes  the  pa- 
tient to  put  off  the  bowel  movement  as  long  as  possible, 
and  when  he  does  defecate,  the  hard  fecal  masses  cause 
more  pain  and  discomfort  than  before.  Digital  examina- 
tion reveals  a  fissure  with  more  or  less  indurated  sur- 
rounding tissue  situated  most  often  at  the  posterior  com- 
missure, or  in  either  the  right  or  left  latero-posterior 
quadrants. 

Ulcer  of  the  rectum  may  be  incorrectly  diagnosed  as 
hemorrhoids,  on  account  of  more  or  less  slight  hemor- 
rhage which  may  accompany  it.  Ulcer,  however,  is  usu- 
ally accompanied  by  diarrhoea;  and  ocular  examination, 
after  eliciting  a  history  of  blood  in  the  stool,  will  settle 
the  diagnosis  at  once.  The  same  may  be  said  of  proctitis ; 
an  intensely  congested  and  injected  rectal  mucous  mem- 
brane may  bleed  on  stool,  but  if  the  conscientious  practi- 
tioner examines  every  patient  who  presents  the  symptom 
of  blood  in  the  stool,  many  sources  of  hemorrhage  other 

13 


188  DIFFERENTIAL   DIAGNOSIS. 

than  piles  will  be  detected  and  the  correct  diagnosis  made. 

Of  course  the  one  important  thing  always  to  bear  in 
mind  when  the  symptom  of  hemorrhage  is  present,  is  the 
possibility  of  the  presence  of  cancer.  Cancer,  well  ad 
vanced,  may  be  found  in  patients  who  present  the  appear- 
ances of  perfect  health.  When  a  patient  of  any  age, 
from  childhood  up  (just  as  often  below  40  as  above),  pre- 
sents a  history  of  rectal  hemorrhage,  which  has  been  pre- 
ceded by  more  or  less  digestive  disturbance,  including 
diarrhoea  alternating  with  constipation  of  several  weeks 
or  months  standing,  with  considerable  intestinal  gas — 
even  though  there  is  no  evidence  of  cachexia  or  loss  of 
weight;  one  should  be  extremely  suspicious  of  malig- 
nancy somewhere  in  the  intestinal  tract.  If  the  blood  is 
of  a  dark  color,  either  of  a  tarry  nature  or  genuine  coffee 
ground,  the  location  of  the  cancer  is  higher  up.  If  the 
blood  is  fresh,  bright  red  in  color  and  closely  follows  the 
stool,  and  has  a  more  or  less  nauseating  odor  accompany- 
ing it  (an  odor  which  is  almost  pathognomonic) ;  one 
should  examine  very  carefully  for  commencing  cancer  in 
the  rectum  or  sigmoid.  When  one  considers  that  fifty 
per  cent  of  all  cancers  occur  in  the  gastro-intestinal  tract, 
and  when  one  realizes  that  sixteen  per  cent  of  all  cancers 
of  the  digestive  tract  occur  in  the  rectum  or  sigmoid,  one 
can  readily  understand  how  important  it  is  to  examine 
every  case  which  presents  the  symptom  of  rectal  hemor- 
rhage. 

Various  protrusions  may  be  mistakenly  diagnosed  for 
hemorrhoids.  Polypi,  which  may  occur  at  any  age,  but  oc- 
cur more  often  in  children,  protrude  with  the  stool.  They 
are  harder,  more  fibrous  in  character  than  hemorrhoids, 
and  when  replaced  by  the  finger,  go  back  into  the  rectum 


DIFFEKENTIAL,   DIAGNOSIS.  189 

with  more  or  less  of  a  snap,  which  is  somewhat  character- 
istic of  this  condition.  Anoscopic  examination  shows  the 
polypus  to  be  a  small,  rounded,  hard,  fibrous  tumor,  at- 
tached by  a  pedicle  narrower  than  itself;  its  attachment 
being  somewhat  higher  in  the  lower  rectal  cavity  than  that 
of  a  hemorrhoid.  Enlarged  rectal  papillae  have  been  diag- 
nosed as  connective  tissue  piles.  The  enlarged  papilla, 
however,  is  small,  always  triangular,  and  occasionally 
long  drawn  out  and  somewhat  ribbon  shaped.  It  is  pink- 
ish in  color;  does  not  contain  varicose  veins.  The  point 
or  tip  is  always  downward,  and  it  is  attached  by  its  base 
or  widest  portion.  They  are  situated  at  the  juncture  of 
the  anus  and  rectum,  at  the  lower  edges  of  the  crypts  of 
Morgagni. 

Venereal  warts  of  large  size  have  been  incorrectly 
diagnosed  as  external  integumentary  piles,  but  close  in- 
spection after  obtaining  a  history  of  discharge  from  vene- 
real disease,  should  make  the  diagnosis  evident.  Occa- 
sionally the  protrusion  of  an  anal  or  peri-anal  abscess 
may  simulate  an  inflamed  external  hemorrhoid.  However, 
with  the  finger  of  one  hand  in  the  rectum  and  the  other 
hand  on  the  protrusion,  the  site  of  the  abscess  cavity  can 
be  made  out  and  fluctuation  often  determined.  The  sud- 
den onset,  accompanied  by  the  intense  pain,  swelling,  red- 
ness and  rise  of  temperature  always  point  to  abscess 
formation  rather  than  hemorrhoid. 

The  protrusion  which  is  often  diagnosed  as  prolapsed 
hemorrhoids  is  prolapsus  ani  or  recti.  There  are  three 
degrees  of  prolapsus :  1.  Simple  eversion  of  the  anal  mu- 
cous membrane.  2.  The  descent  outside  of  the  rectum  of 
more  or  less  of  all  coats  of  the  rectum.  3.  The  descent  of 
the  entire  rectum  with  more  or  less  of  the  sigmoid,  which 


1  90  TREATMENT PALLIATIVE. 

may  come  down  to  the  anal  orifice  but  not  necessarily 
protrude.  Prolapsed  mucous  membrane  is  differentiated 
from  prolapsed  hemorrhoids  by  its  smooth,  velvety  touch, 
reddish  color,  and  the  absence  of  varicose  veins.  It  is 
continuous  with  the  rectal  mucous  membrane  and  a  dis- 
tinct sulcus  can  be  made  out  between  the  anus  and'  the 
protrusion  in  the  second  and  third  varieties.  In  the  first 
variety,  careful  examination  will  show  it  to  be  mucous 
membrane  continuous  with  the  anal  skin.  Of  course  in 
aggravated  cases  of  prolapsed  hemorrhoids  more  or  less 
prolapsus  of  the  mucous  membrane  of  the  anus  will  ac- 
company it,  and  the  diagnosis  is  self-evident. 

Treatment.  The  treatment  of  hemorrhoids  we  will 
divide  into  palliative  and  radical. 

The  palliative  treatment  of  hemorrhoids  is,  however, 
not  a  cure,  but  a  relief  of  acute  symptoms  for  a  more  or 
less  short  period  of  time.  When  a  patient  presents  him- 
self suffering  from  acute  prolapsed  internal  hemorrhoids 
with  more  or  less  strangulation  by  a  reflexly  contracted 
sphincter,  the  first  thing  to  do  is  to  reduce  the  prolapse. 
This  is  not  always  as  easy  as  it  seems.  The  reflex  con- 
traction of  the  sphincter  on  the  hemorrhoids  shuts  off  the 
return  blood  supply  and  the  hemorrhoid  swells  so  much 
that  it  cannot  be  replaced  without  anesthesia.  If,  how- 
ever, a  solution  of  adrenalin  chloride  (1-1000)  or  gly- 
cerine be  applied  by  means  of  compresses,  the  blood  ves- 
sels will  shrink  to  such  an  extent  that  reduction  is  often 
easy.  Sometimes  the  application  of  cold  or  alum  solu- 
tions will  cause  sufficient  shrinking  to  make  reduction 
easy.  Chloretone,  one-half  of  one  per  cent,  or  eucaine 
one  to  four  per  cent  may  be  added  to  these  solutions  to 
render  them  anesthetic.  Occasionally  applications  of 


CAUTERIZATION INJECTION   METHOD.  .        191 

fluid  extract  of  ergot  will  help  in  maintaining  the  con- 
traction of  the  vessels  after  adrenalin  has  brought  them 
down.  An  ointment  containing  adrenalin,  one  to  one 
thousand,  chloretone  20  grains  to  the  ounce  in  lanolin, 
injected  into  the  anus  after  stool  and  three  or  four  times 
a  day,  at  regular  intervals  through  a  long  nozzled  collap- 
sible tube ;  will  often  assist  in  allaying  an  acute  attack  of 
hemorrhoids.  However,  all  of  these  treatments  are  mert*> 
ly  palliative,  and  the  hemorrhoid  upon  the  slightest  irri- 
tation, will  enlarge,  prolapse  and  even  strangulate  again. 

Some  patients  who  absolutely  refuse  more  ^radical 
measures  will  submit  to  cauterization  of  the  hemorrhoid 
by  the  thermo-cautery,  thus  causing  a  deposition  of  scar 
tissue  on  the  surface  of  the  hemorrhoid  which  by  its  con- 
traction somewhat  lessens  its  size,  and  repeated  applica- 
tions of  the  cautery  will  reduce  the  hemorrhoid  so  that  it 
will  not  be  noticeable  for  some  time.  Occasionally  such 
irritants  as  glacial  acetic  acid,  chromic  acid,  and  100  per 
cent  solution  of  nitrate  of  silver,  have  been  used  for  «i 
like  purpose.  The  puncture  of  the  hemorrhoidal  mass  in 
various  places  by  means  of  the  electric  needle,  as  advo- 
cated by  Kelsey,  has  been  of  some  assistance  in  reducing 
the  size  of  internal  hemorrhoids,  but  never  entirely  re- 
moves them. 

The  "injection  treatment,"  which  is  the  treatment  usu- 
ally advocated  by  most  of  the  irregulars,  may  be  applied 
in  a  number  of  ways.  The  patient's  rectum  is  cleansed 
by  means  of  a  simple  enema,  followed  by  one  of  the  satu- 
rated solution  of  boric  acid  or  some  other  antiseptic.  The 
hemorrhoid,  which  should  be  of  the  prolapsing  variety 
and  one  that  can  be  easily  extruded  into  the  ano scope,  or 
outside,  is  injected  down  to  its  base  with  either  a  mild 


192  THE  INJECTION  TREATMENT. 

solution  containing  carbolic  acid  up  to  five  or  ten  per 
cent,  if  one  wishes  to  cause  a  mild  inflammation  and 
gradual  occlusion  of  the  blood  vessels  by  the  deposition 
of  fibrous  tissue ;  or  by  a  strong  solution  of  carbolic  acid 
running  from  20  per  cent  to  50  per  cent,  when  one  wishes 
an  immediate  slough  of  the  hemorrhoidal  mass. 

When  one  has  but  one  or  two,  or  not  to  exceed  four, 
prolapsing  hemorrhoids,  this  method  may  be  applicable, 
each  hemorrhoid  being  injected  at  the  time.  In  some 
cases  two  or  three  injections  are  necessary  for  each  hem- 
orrhoid at  intervals  of  five  or  six  days,  but  on  account  of 
the  danger  of  injecting  a  blood  vessel,  and  on  account  of 
the  inability  to  limit  the  slough  caused  by  carbolic  acid, 
it  is  rather  an  unsafe  method,  and  repeated  instances  of 
destruction  of  large  areas  of  tissue,  and  sepsis,  have 
been  reported. 

A  rather  ingenious  method  of  applying  the  injection 
treatment  has  been  advocated  by  Franck  of  Berlin.  He 
employs  a  50  per  cent  solution  of  carbolic  acid  in  alco- 
hol, and  uses  it  as  follows :  The  hemorrhoid  is  rendered 
tense  by  the  application  of  a  wire  snare  around  its  base ; 
this  is  gradually  tightened  so  as  to  cause  the  tumor  to 
be  slowly  congested ;  the  needle  is  then  planted  in  the  cen- 
ter of  the  mass  and  several  drops  of  the  solution  slowly 
injected.  The  snare  is  not  removed  until  the  whole  mass 
has  undergone  thrombosis.  Each  time  it  is  treated  in  a 
like  manner  and  a  dressing  of  some  drying  powder  is 
applied.  In  seven  or  eight  days  the  necrotic  tissue  will 
slough  off  and  the  granulating  surface  will  be  healed  in 
three  or  four  weeks. 

This  long  period  of  granulation  is  another  objection  to 
the  application  of  the  injection  method.  With  the  intro- 


OPERATIVE   TREATMENT.  193 

dtiction  of  local  anesthesia  in  the  radical  treatment  of  rec- 
tal disease,  the  field  for  the  injection  method  has  been 
greatly  encroached  upon.  It  seems  to  the  author  much 
more  rational  to  remove  the  hemorrhoid  by  a  clean  cut 
surgical  incision,  under  local  anesthesia,  and  have  the  pa- 
tient up  and  about  on  the  second  day,  and  the  wound 
healed  in  from  a  week  to  ten  days  (this  under  local  anes- 
thesia in  office  practice),  than  to  use  the  uncertain,  un- 
scientific injection  methods.  Therefore,  the  author  will 
confine  himself  in  this  chapter  to  a  description  of  the  va- 
rious methods  of  operating  on  hemorrhoids  under  local 
anesthesia,  as  applicable  in  office  practice. 

Operative  Treatment  Under  Local  Anesthesia.  The 
technique  of  producing  local  anesthesia  is,  briefly,  as  fol- 
lows (see  Chap.  XV.) : 

Your  patient,  who  has  previously  had  a  cleansing  and 
antiseptic  enema,  is  placed  upon  the  table  in  the  Sim's 
position.  A  large  glass  hypodermic  syringe  is  filled  with 
the  solution  of  choice  which  may  be  cocaine,  eucaine.  aly- 
pin,  chloretone  or  simple  sterilized  water,  as  the  case  may 
demand.  Beta  eucaine  lactate,  any  strength  varying  from 
one-half  to  one-tenth  of  one  per  cent,  is  used  for  anes- 
thetizing the  sphincter  and  is  injected  in  this  wise :  After 
sterilizing  the  parts,  a  point  one-half  inch  below  and  pos- 
terior to  the  posterior  commissure  of  the  anus  is  selected. 
A  spray  of  ethyl  chloride  or  a  drop  of  pure  carbolic  acid 
is  used  to  deaden  the  pain  which  accompanies  the  intro- 
duction of  the  needle.  With  one  index  finger  in  the  anus, 
hooking  down  the  sphincter,  the  needle  in  the  other  hand 
is  passed  inward,  upward  and  laterally,  in  a  V-shaped  di- 
rection for  about  three-fourths  of  an  inch,  going  down 
into  the  sphincter  muscle,  but  not  through  it.  From  ten 


194  LOCAL   ANESTHESIA. 

drops  to  a  drachm  of  the  solution  is  slowly  injected  and 
the  needle  is  retracted  to  the  point  of  puncture,  but  not 
withdrawn ;  then  it  is  pushed  up  on  the  other  side  in  the 
same  manner,  keeping  about  one-half  inch  away  from  the 
anal  aperture. 

Then  three  or  four  minutes  are  allowed  to  pass  to  give 
the  anesthetic  time  to  take  effect.  Then  a  vibrator,  armed 
with  a  cone-shaped  vibratode,  well  lubricated,  is  pressed 
against  the  anus.  About  three  minutes  of  rapid  vibra- 
tion will  dilate  the  sphincter  painlessly  to  a  sufficient  cali- 
ber to  allow  the  operation  to  proceed  without  difficulty. 
In  the  absence  of  the  vibrator,  one  may  use  the  index 
fingers  of  both  hands,  protected  by  finger  cots,  and  by  a 
gentle  massage  movement  gradually  accomplish  the  same 
object  in  a  slightly  longer  period  of  time. 

When  the  sphincter  is  dilated,  the  hemorrhoid  is  in- 
jected, from  its  base  to  its  apex,  with  plain  sterilized  wa- 
ter, or  an  extremely  mild  anesthetic  solution,  such  as  one- 
tenth  of  one  per  cent  of  eucaine  lactate.  The  particular 
point  to  remember  is  that  distension  must  be  carried  until 
the  tissues  are  blanched  and  the  hemorrhoid  is  in  appear- 
ance not  unlike  a  Malaga  grape. 

I  very  seldom  find  it  necessary  to  ligate  any  vessels,  as 
their  retraction  very  soon  causes  the  hemorrhage  to  cease. 

The  operation  is  then  proceeded  with  according  to  the 
technique  outlined  below. 

A  suppository  containing  three  grains  of  thymol  iodide, 
two  grains  of  chloretone  and  two  grains  of  powdered 
opium  is  inserted  and  a  dressing  applied,  but  the  patient 
is  not  allowed  to  get  up  from  the  table  for  about  ten 
minutes ;  then  is  asked  to  rise  slowly  and  either  sit  down 
or  lie  down  as  he  wishes.  I  have  found  that  when  a  pa- 


EXCISION TECHNIQUE.  195 

tient  is  allowed  to  get  up  immediately,  some  dizziness  or 
faintness  is  complained  of,  and  I  formerly  attributed  it 
to  the  chemical  anesthetics  injected,  until  I  found  that  it 
also  occurred  in  those  patients  in  whom  sterile  water 
alone  was  used  as  an  anesthetic. 


Fig.  86. 
Method  of  Injecting  Prolapsing  Pedunculated  Internal  Hemorrhoids. 

Excision. — The  hemorrhoid  having  a  pedicle  is  injected 
at  its  base  with  sterile  water  or  weak  eucain  solution — the 
distension  carried  to  blanching  of  the  tissues,  the  base 
transfixed  with  a  double  threaded  needle  (linen  suture 
being  used),  and  the  ligature  double  tied.  The  hemorrhoid 
is  then  cut  off,  leaving  a  sufficient  stump  to  prevent  slip- 
ping of  the  ligature.  Each  one  is  treated  in  like  manner,  a 
suppository  of  the  composition  mentioned  above  inserted, 
the  bowels  kept  locked  up  for  from  three  to  five  days,  and 


196  EXCISION TECHNIQUE. 

the  patient  allowed  to  be  up  and  around  after  the  first 
twenty-four  hours.  The  patient  is  sent  home  usually  in  a 
carriage  (occasionally  they  will  walk  or  take  the  car), 
and  is  advised  to  lie  on  either  one  side  or  the  other  for 
twenty-four  hours  and  then  resume  his  occupation.  It  is 
surprising  with  how  little  discomfort  they  are  able  to  get 
around  and  how  quickly  they  recover. 


Fig.  87. 

Author's   Hemorrhoidal   Forceps. 

Provided  with  a  "Battle  Axe"  shaped  extremity,  whose  edge  is  serrated, 

instead   of   toothed. 

In  the  author's  bloodless  operation  for  hemorrhoids  this  is  a  very 
useful  instrument  ,for  grasping  the  tumor  without  puncturing  or  lacer- 
ating it. 

The  hemorrhoid  which  is  sessile  or  non-pedunculated,  is 
distended  in  the  same  manner  as  above.  The  most  depend- 
ent portion  is  grasped  with  the  author's  pile  forceps  (Fig. 
87)  or  toothed  forceps;  it  is  dissected  up  from  its  base 
with  either  knife  or  scissors  to  healthy  tissue,  care  being 
taken  to  include  in  the  dissection  the  vessels  which  enter 
the  hemorrhoid  from  above.  The  upper  part  of  the  flap  is 
transfixed  and  tied  off,  as  is  the  pedicle  in  the  above  va- 
riety, when  the  tumor  is  cut  off  with  the  scissors;  others 
treated  in  like  manner,  and  the  after-treatment  is  the 
same  as  above.  It  is  a  very  rare  thing  for  the  author  to 
have  hemorrhage  severe  enough  to  require  ligation  of 
the  vessels.  Where  there  is  more  or  less  oozing,  a  piece 
of  rubber  tubing,  about  four  inches  long  and  surrounded 


AUTHOR  S    BLOODLESS    OPERATION. 


197 


by  gauze,  is  inserted,  and  the  pressure  of  the  gauze 
against  the  raw  surface  very  soon  checks  oozing.  This 
is  removed  in  anywhere  from  one  to  twenty-four  hours. 
Author's  Bloodless  Operation. — A  somewhat  simple 
method  is  the  author's  technique  for  the  removal  of  cer- 
tain forms  of  internal  hemorrhoids  without  the  profuse 
hemorrhage  with  which  this  operation  is  usually  associ- 
ated in  the  minds  of  most  medical  practitioners.  From 
the  observation  that  most  patients  suffering  from  hemor- 
rhoids of  the  itnernal  variety  are  more  or  less  anemic 
from  the  continued  and  constant  loss  of  blood,  as  a  result 
of  their  hemorrhoidal  trouble,  I  decided  to  use  a  tech- 
nique which  would  minimize  operative  hemorrhage  and 


Fig.  88. 
Rectal  Retractor   Modified  from  Sims'  Speculum. 

conserve  the  patient's  blood  supply.  With  this  aim  in 
view,  I  have  developed  and  have  been  using  a  very  simple 
technique  which  I  present  below: 


198 


AUTHOR  S    BLOODLESS    OPERATION. 


It  is  applicable  under  local  as  well  as  general  anesthe- 
sia, and  therefore  can  be  used  in  those  weak,  run-down 
patients  suffering  from  any  of  the  wasting  diseases,  in 
whom  the  use  of  a  general  anesthetic  would  be  inadvis- 
able, if  not  positively  dangerous.  The  method  is  appli- 
cable to  any  variety  of  internal  hemorrhoids  and  particu- 
larly to  the  pedunculated  and  prolapsing  varieties.  Tn- 
terno-external  hemorrhoids  can  also  be  treated  by  this 
method.  Very  few  instruments  are  required  and  in  most 
cases,  dilatation  of  the  sphincters  is  not  required.  The 
technique  under  general  anesthesia  is  much  the  same  as 
under  local  anesthesia,  and  inasmuch  as  local  anesthesia 
is  a  good  deal  safer  and  fully  as  satisfactory  as  general 
anesthesia  for  this  work;  the  author  will  describe  the 
operation  as  performed  by  him  under  local  anesthesia. 


Fig.  89. 
Author's  Blunt  Pointed  Ligature  Carrier. 

This  instrument  is  very  useful  in  the  author's  bloodless  operation  for 
hemorrhoids,  for  passing  the  ligature  under  the  blood  vessels  of  the  hem- 
orrhoid;  its  blunt  extremity  preventing  the  puncture  or  injury  of  the 
vessels. 

The    instruments    required    are    a    rectal    retractor 
(Fig.  88),  or  Sim's  speculum;  the  author's  blunt  pointed 


AUTHOR  S    BLOODLESS    OPERATION. 


199 


ligature  carrier  (Fig.  89),  the  author's  pile  forceps 
(Fig.  87),  scalpel,  sharp  pointed  scissors  curved 
on  the  flat  (Fig.  54),  aseptic  hypodermic  syringe  with 
sharp  needle  and  sterile  cat-gut.  The  patient  is  given 
one-fourth  grain  of  morphine  about  twenty  minutes  be- 
fore the  operation  is  performed;  the  bowels  are  washed 
out  with  a  soap  suds  enema,  followed  by  a  boracic  acid 
enema.  He  is  then  placed  on  the  operating  table  in  the 
Sim's  lateral  position;  the  skin  around  the  anus  is  scrub- 
bed, shaved,  and  sterilized.  The  sphincters  are  then  anes- 
thetized by  the  injection  of  20  to  30  minims  of  one-half 


Fig.  90. 
Technique  cf  Author's  Bloodless  Operation  for  Internal  Hemorrhoids. 

A.  Method   of    inserting   ligature    carrier    threaded    with    catgut. 

B.  Showing  ligature   tied,  thus  constricting  the   blood   vessels   supplying 

the   hemorrhoid. 

C.  Removal    of   the   hemorrhoidal   mass   without    sacrificing   the    mucous 

membrane. 


200  AUTHOR'S  BLOODLESS  OPERATION. 

of  one  per  cent  beta-eucain  lactate  solution  which  has 
been  sterilized  by  boiling,  according  to  the  technique  de- 
scribed above. 

When  dilatation  has  been  accomplished,  the  most  de- 
pendent hemorrhoid  is  injected  with  one-tenth  of  one  per 
cent  solution  of  eucaine  lactate  or  sterile  water,  and  the 
distension  carried  until  the  tissues  are  blanched.  Anes- 
thesia is  then  complete.  The  lower  extremity  of  the  hem- 
orrhoid is  then  grasped  with  the  author's  pile  forceps 
and  pulled  down  so  that  it  is  on  the  stretch.  The  blunt- 
pointed  ligature  carrier,  threaded  with  No.  2  cat-gut,  is 
passed  in  through  the  mucous  membrane  on  one  side, 
down  to  the  base  of  the  hemorrhoid  and  around  to  the 
opposite  side,  in  such  a  manner  as  to  include  the  upper 
half  of  the  mucous  membrane  covering  the  pile,  and  the 
blood  vessels  underneath,  but  not  encircling  the  entire 
hemorrhoid  as  in  ligating  a  pedicle  (Fig.  90- A).  This 
ligature  should  be  placed  just  at  the  juncture  of  the  pile 
and  the  healthy  mucous  membrane  of  the  rectum.  It  is 
then  firmly  tied  (Fig.  90-B),  and  it  will  be  found  that  the 
blood  supply  of  the  pile  has  been  included  in  the  ligature 
and  shut  off.  The  piles  at  either  side  are  dealt  with  in 
like  manner  and  lastly  the  upper  ones.  A  suppository 
containing : 

Chloretone  gr.  ii 

Thymol   iodide   gr.  ii 

Powdered  opium gr.  ii 

is  inserted,  the  patient  keeping  in  the  recumbent  position 
for  ten  minutes,  and  then  allowed  to  rise  from  the  table 
and  go  to  his  bed.  There  will  be  considerable  swelling 
during  the  first  24  hours,  but  this  with  its  accompanying 


AUTHOR  S  BLOODLESS  OPERATION.  201 

pain,  can  be  relieved  by  the  application  of  hourly  com- 
presses soaked  in  the  following  solution : 

1* 

Adrenalin  chloride  (1  to  1000) i/o  ounce. 

Chloretone 30  grains. 

Glycerine    4  ounces. 

Water   4  ounces. 

This  swelling  subsides  in  from  two  to  four  days  and 
the  pile  gradually  shrinks  until  at  the  end  of  four  weeks, 
there  is  nothing  left  but  a  little  hard  "nub"  of  connect- 
ive tissue  which  can  be  snipped  off  painlessly  with  the 
scissors  at  any  time.  This,  which  is  the  simplest  form  of 
technique,  is  applicable  to  those  desperate  cases  of  anemia 
where  the  continual  loss  of  blood  from  the  hemorrhoids 
is  greater  than  the  patient's  blood  production.  It  can 
be  done  in  from  ten  to  fifteen  minutes'  time,  and  involves 
the  least  expenditure  of  nerve  endurance  and  suffering 
of  the  patient.  In  cases  where  the  necessity  for  haste 
is  not  quite  so  imperative,  I  use  the  following  modification 
of  the  technique: 

After  the  hemorrhoid  is  anesthetized  as  above,  and  the 
ligature  applied  in  the  same  manner,  the  pile  is  grasped 
in  the  author's  pile  forceps  and  an  incision  made  in  its 
longtitudinal  axis,  starting  about  one-quarter  of  an  inch 
from  the  ligature  and  extending  down  to  its  distal  ex- 
tremity, then  with  the  curved  scissors,  the  blood  vessels 
and  connective  tissue  which  make  up  the  body  of  the  pile, 
are  dissected  out  en  masse  (Fig.  90-C)  and  cut  off  about 
one-quarter  of  an  inch  from  the  ligature.  The  wound  is 
left  open  to  heal  by  granulation,  which  it  does  in  a  very 
few  days.  This  dispenses  with  the  hemorrhoid  at  once 


202  AUTHOR'S  BLOODLESS  OPERATION. 

and  does  away  with  the  swelling,  pain,  and  discomfort 
which  necessarily  follows  the  preceding  technique. 

In  cases  where  we  have  peduncnlated,  prolapsing  hem- 
orrhoids, it  is  not  necessary  to  dilate  the  sphincter  or  use 
the  speculum.  Following  an  enema,  the  patient  is  asked 
to  strain  while  in  the  squatting  position  or  lying  on  his 
side,  while  the  operator  is  everting  and  pressing  back  the 
sphincter  muscles  by  pressure  just  outside  of  the  outer 
margins  of  the  external  sphincters.  The  pile  which  is 
prolapsed  by  this  method  is  injected  with  the  weaker 
anesthetic  solution.  Its  pedicle  is  transfixed  with  the 
blunt  ligature  carrier  double  threaded  with  cat-gut  and 
tied  off  in  two  sections.  The  pile  is  then  cut  away  one- 
quarter  of  an  inch  from  the  ligature,  and  the  stump  cau- 
terized with  95  per  cent  carbolic  acid.  The  other  pedun- 
culated  hemorrhoids  are  treated  in  like  manner,  the  anal- 
gestic  supository  inserted,  and  the  operation  is  com- 
pleted. 

The  after  care  is  very  simple,  the  bowels  being  con- 
fined for  from  three  to  five  days.  A  drachm  of  compound 
licorice  powder  at  night  followed  by  a  six  to  ten  ounce  oil 
enema  in  the  morning,  will  produce  an  easy  and  satisfac- 
tory movement  at  the  end  of  that  time.  A  teaspoonful  of 
liquid  albolene  before  each  meal  will  keep  the  bowels  in 
good  order  and  daily  soft  movements  will  follow.  The 
only  dressing  required  is  some  drying  and  protective 
powder  such  as  compound  stearate  of  zinc,  which  should 
be  applied  sufficiently  often  to  keep  the  parts  protected. 
Some  of  the  many  advantages  of  this  method  are  as 
follows : 


SUBMUCOUS  EXCISION.  203 

1.  The  technique  is  simplicity  itself. 

2.  It  is  applicable  under  local  anesthesia. 

3.  It  takes  a  shorter  time  than  any  other  method  which 
successfully  disposes  of  the  hemorrhoid. 

4.  It  is  surer,  safer,  and  quicker  than  the  "injection 
method,"  and  is  applicable  in  every  case  where  the  injec- 
tion method  can  be  used,  as  well  as  in  other  varieties  of 
hemorrhoids  where  the  injection  is  contra-indicated. 

5.  It  should  be  the  method  of  choice  in  all  patients 
suffering  from  anemia,  tuberculosis,  hemophilia,  and  in 
pregnancy ;  because  of  all  the  foregoing  reasons,  and  the 
fact  that  it  doesn't  involve  the  loss  of  blood.    The  prin- 
ciple of  tying  before  cutting  reduces  the  waste  of  blood 
to  a  minimum,  and  makes  for  rapid  convalescence. 

6.  There  being  no  confinement  to  bed  after  the  first  24 
hours,  the  patient  may  be  up  and  about,  going  out  of 
doors,  getting  fresh  air,  sunlight  and  exercise,  which  are 
nature's  best  curative  agents  in  convalescence  after  any 
operation  or  disease,  and  of  the  greatest  value  to  patients 
suffering  from  any  of  the  wasting  diseases  mentioned 
above. 

Submucous  Excision. — In  the  sessile  variety,  an- 
other way  of  treating  these  is  simply  to  make  an 
incision  in  the  longitudinal  axis  of  the  bowel  through 
the  center  of  the  mass,  and  then  by  the  use  of  the  author's 
angular  rectal  scissors  (Fig.  48)  to  macerate  and  de- 
stroy the  blood  vessels  beneath  the  mucous  membrane  on 
either  side  of  the  incision.  The  blood  supply  being  de- 
stroyed and  the  macerated  tissue  cleaned  out  with  a 
curette,  the  wound  is  allowed  to  heal  without  suture,  and 
usually  does  so  in  four  or  five  days.  Of  course  this  method 
is  accompained  by  some  hemorrhage,  but  never  severe 


14 


204  CONTRA-INDICATED   METHODS. 

enough,  however,  to  require  ligature.  The  after-treat- 
ment is  the  same  as  in  the  other  varieties. 

The  clamp  and  cautery  operation  is  not  applicable,  of 
course,  under  local  anesthesia,  and  I  mention  it  merely  to 
condemn  it.  I  do  not  believe  that  the  use  of  a  red-hot  iron 
in  a  cavity  lined  with  mucous  membrane  is  rational,  and 
while  I  am  aware  that  many  surgeons  have  used  it  with 
many  successful  results,  I  have  seen  strictures  following 
its  use  which  were  caused  by  the  overgrowth  of  scar  tis- 
sue— which  is  more  prone  to  follow  a  burn  than  any 
other  form  of  wound.  A  clean  cut  surgical  incision,  to 
my  mind,  is  more  rational  and  is  not  followed  by  the  ex- 
tensive sloughing  or  the  extensive  cicatrix.  Crushing  the 
hemorrhoid  with  the  angiotribe  has  also  been  used  by 
some  operators,  and  offers  the  objection  that  it  destroys 
too  much  mucous  membrane  and  is  followed  by  a  more  or 
less  chronic  granulating  surface  taking  weeks  to  heal. 

The  Whitehead  operation  is,  in  the  author's  opinion, 
very  seldom,  if  ever,  indicated. 

Other  methods  of  disposing  of  large  redundant  hemor- 
rhoidal  masses  by  means  of  elliptical  flaps,  longitudinal 
incisions,  and  plastic  work,  are  used  to  obviate  the  neces- 
sity of  doing  any  operation,  which  is  almost  certain  to  be 
followed  by  sepsis,  retraction  of  flaps  and  subsequent 
cicatricial  contraction;  and  the  writer  has  yet  to  see  a 
case  of  hemorrhoids  accompanied  by  prolapse,  so  severe 
that  he  has  not  been  able  to  remedy  it  without  sacrificing 
the  normal  contour  of  the  anus.  These  last  varieties  have 
been  mentioned  simply  because  no  chapter  on  the  treat- 
ment of  hemorrhoids  will  be  complete  without  their  re- 
cognition by  some  mention  at  least. 


ACUTE  THROMBOTIC  HEMORRHOIDS.  205 

The  acute  thrombotic  variety  (Fig.  79)  is  peculiarly 
amenable  to  treatment  under  local  anesthesia.  On  account 
of  its  sudden  onset  and  the  acute  suffering  which  it  pro- 
duces, the  patient  will  present  himself  for  treatment  with- 
in a  very  few  hours  after  its  onset.  Examination  in  the 
lateral  position  shows  a  rounded,  bluish  or  purplish  tu- 
mor varying  in  size  from  that  of  a  pea  to  a  large  grape, 
located  just  at  the  anal  margin  usually  on  one  side.  It 
usually  occurs  singly.  After  the  usual  preparation,  the 
hemorrhoid  is  injected  from  its  outermost  aspect  with  10 
or  12  drops  of  one-half  of  one  per  cent  solution  of  eucain 
lactate — the  injection  being  carried  just  underneath  the 
skin  or  mucous  membrane,  and  not  down  into  the  pile. 
After  allowing  a  minute  or  two  for  the  anesthetic  to  take 
effect,  an  incision  is  made  through  the  skin  and  down  to 
the  clot,  parallel  to  the  long  axis  of  the  anus  and  extend- 
ing for  about  a  quarter  of  an  inch  into  the  skin  beyond  the 
tumor.  The  tissues  around  the  tumor  and  below  it  are  in- 
jected with  one-tenth  of  one  per  cent  solution  of  eucain, 
when  it  is  dissected  out  by  means  of  a  small  toothed  for- 
cep  and  the  scissors  curved  upon  the  flat.  After  the  clot 
(Fig.  80)  is  removed,  look  carefully  into  the  wound 
to  see  whether  a  second  clot  has  formed  below,  and  if  so, 
it  must  be  removed  at  the  same  time.  The  edges  of  the 
wound  are  trimmed  back  in  an  elliptical  manner,  so  as  to 
leave  a  gaping  wound,  which  will  heal  by  granulation 
from  the  bottom,  without  any  possibility  of  the  edges  of 
the  wound  turning  in  and  retarding  its  healing.  A  one- 
half  inch  strip  of  chloretonized  tape  or  gauze  is  lightly 
inserted  into  the  wound  and  a  sterile  dressing  applied. 
This  gauze  is  removed  in  24  hours,  when  it  will  not  be 
found  necessary,  as  a  general  rule,  to  re-pack  the  wound. 


EXTERNAL  HEMORRHOIDS. 

It  should  be  seen  and  dressed  daily,  and  some  mild  anti- 
septic powder  applied  such  as  thymol-iodide,  boric  acid, 
boro-chloretone,  stearate  of  zinc,  or  acetanilid.  The  pa- 
tient after  this  operation,  experiences  a  keen  sense  of 
relief  almost  from  the  start  from  the  relief  of  the  tension 
caused  by  the  thrombotic  mass. 

The  removal  of  external  hemorrhoids  of  the  integumen- 
tary (Fig.  52)  variety  is  very  easily  accomplished  under 
local  anesthesia.  After  the  parts  are  prepared,  shaved  and 
sterilized  with  the  patient  placed  in  the  left  lateral  or  lith- 
otomy position,  the  most  dependent  pile  is  selected,  the 
point  of  puncture  touched  with  a  drop  of  pure  carbolic 


Fig.  91. 

Distension  of  External  Hemorrhoids  With  Sterile  Water. 

This  photograph  of  one  of  the  author's  cases  shows  the  amount  of 
distension  necessary  to  produce  anesthesia  with  plain  sterile  water.  This 
is  taken  from  the  same  case  as  figure  52  and  comparison  of  the  two 
will  be  of  interest. 


TREATMENT    OF   EXTERNAL   HEMORRHOIDS.  207 

acid  or  sprayed  with  ethyl  chloride  until  the  tissues  are 
blanched,  when  the  spray  is  removed,  and  as  soon  as  they 
have  regained  their  natural  color  the  injection  is  made.  As 
in  all  operations  involving  the  skin,  the  first  injection 
should  be  of  one-half  of  one  per  cent  solution  of  eucain  lac- 
tate,  care  being  taken  to  inject  the  first  ten  or  fifteen  drops 
just  underneath  the  skin  along  the  line  of  the  proposed 
incision  so  as  to  form  a  wheal  or  welt.  An  incision  is 
then  made  on  a  line  radiating  at  right  angles  from  the 
anal  orifice  to  the  distal  extremity  of  the  tumor,  then  the 
subcutaneous  tissues  are  infiltrated  with  one-tenth  of  one 
per  cent  eucain  solution  or  one-half  of  one  per  cent  solu- 
tion of  chloretone,  or^  sterile  water.  The  hemorrhoidal 
mass  is  then^eized  with  the  author's  hemorrhoidal  for- 
cepts  and  removed  with  a  flat  pair  of  scissors.  The  skin 
edges  are  trimmed  back  on  either  side  in  the  shape  of  an 
ellipse,  so  as  to  include  all  of  the  redundant  tissue  which 
forms  the  covering  of  the  pile.  One  must  be  cautious 
about  not  cutting  away  too  much  skin.  The  distension 
with  the  anesthetic  solution  somewhat  distorts  and  dis- 
tends the  skin,  and  the  infiltration  extends  beyond  the 
part  to  be  removed,  making  it  appear  much  larger  and  ex- 
tensive than  it  in  reality  is  (Fig.  91).  It  is  a  wise  plan, 
therefore,  to  carefully  mark  out,  before  proceeding  to  op- 
erate, the  extent  of  the  proposed  incision  by  means  of  a 
small  swab  moistened  with  tincture  of  iodine.  Each  hem- 
orrhoid  is  treated  in  like  manner,  working  from  below  up- 
wards, and  the  wounds  lightly  packed  with  chloretonized 
gauze  and  the  wound  allowed  to  heal  by  granulation. 
There  is  no  objection  to  putting  a  couple  of  silk-worm 
stitches  in  each  wound,  if  desired,  but  the  author  has 
found  healing  fully  as  satisfactory  without  stitching  and 


208  AFTER-CARE. 

the  time  of  the  operation  is  materially  lessened,  which  is 
an  important  factor  in  all  work  under  local  anesthesia. 

The  after-care  is  similar  to  that  outlined  in  the  treat- 
ment of  acute  thrombotic  hemorrhoids.  The  healing  fol- 
lowing operation  for  external  hemorrhoids  should  be 
complete  in  a  week  or  ten  days. 

During  the  healing  process,  the  patient  should  be  re- 
quired to  use  an  infllated  air  cushion,  or  pillow,  when  sit- 
ting, and  to  lie  upon  either  side  rather  than  upon  the 
back.  As  has  been  stated  above  in  the  treatment  of  inter- 
nal hemorrhoids,  it  is  wise  to  put  the  patient  upon  a 
light  diet,  consisting  of  meat,  broths  and  strained  veget- 
able soups,  with  the  addition  of  eggs  or  gelatins  for  the 
first  three  or  four  days.  The  bowels  should  be  confined 
and  not  allowed  to  move  until  the  fourth  day,  when,  by 
means  of  a  dose  of  licorice  powder  (one  to  three 
drachms)  given  the  night  before,  and  a  ten  ounce  oil  ene- 
ma, the  bowels  should  be  moved.  The  movements  there- 
after should  be  kept  soft  by  the  administration  of  drachm 
doses  of  refined  petroleum  oil  (liquid  albolene),  four  or 
five  times  daily,  and  the  diet  gradually  increased.  After 
the  first  movement,  daily  evacuations  of  the  bowels  should 
be  procured. 

Where,  on  account  of  the  number  and  redundancy  of 
external  hemorrhoids,  the  operation  for  their  removal 
under  local  anesthesia  would  be  too  extensive  or  involve 
too  much  time  if  attempted  at  one  sitting,  the  work  may 
be  divided ;  half  being  taken  care  of  at  one  time,  and  the 
other  half  after  an  interval  of  two  or  more  weeks.  The 
author  would  not  advise  the  removal  of  more  than  three 
or  four  external  hemorrhoids  at  one  operation.  It  is  very 
rare,  however,  to  find  more  than  this  number  as  a  general 
rule. 


CHAPTER  XL 

RECTAL  POLtPI— HYPERTROPHIED  ANAL 
PAPILLAE— CRYPTITIS. 

A  polypus  is  a  non-malignant  tumor,  whose  chief  char- 
acteristic is  its  attachment  to  the  rectal  wall  by  a  pedicle, 
which  is  always  narrower  than  the  tumor  (Fig.  92).  It  oc- 
curs more  often  in  children  than  in  adults.  Polypi  may  be 
found  singly  or  in  such  large  numbers  as  to  entirely  fill 
the  rectal  cavity,  and  will  be  found  complicating  fissure  in 
ano,  hemorrhoids,  prolapsus,  and  other  rectal  diseases. 

The  usual  location  of  a  polypus  is  in  the  lower  end  of 
the  rectal  canal  from  one  to  two  inches  from  the  anal 
opening.  'Rarely  cases  have  been  seen  in  which  the  poly- 
pus has  been  found  attached  by  a  pedicle  four  or  five 
inches  long  as  high  as  the  recto-sigmoidal  juncture. 

The  types  of  polypi  most  commonly  met  with  are  either 
the  soft  myxomatous  or  adenomatous  variety,  and  the 
hard  fibroid  polypus.  In  appearance,  the  soft  granular 
polypus  resembles  a  raspberry,  and  bleeds  readily  at  the 
touch.  The  fibroid  variety  is  hard,  rounded  and  lighter 
in  color  than  the  normal  rectal  mucous  membrane. 

Symptoms. — The  usual  symptoms  outside  of  the 
appearance  of  the  polypi  itself,  are  the  passage  of  blood, 
mucous,  and  straining  efforts  after  stool ;  the  patient  com- 
plaining of  a  feeling,  as  if  more  fecal  matter  were 

209 


210 


POLYPUS — DIAGNOSIS. 


rectum,  but  it  was  impossible  to  evacuate  it. 

Diagnosis. — The   diagnosis    is   very    simple,    as    they 
are  often  discovered  protruding  from  the  anus.    A  pecu- 


Fig.  92. 
Rectal  Polypus. 


POLYPUS TREATMENT.  211 

liar  characteristic  of  polypi  is  the  snapping  sensation 
which  they  give  to  the  finger  as  they  are  returned  to  the 
rectum.  On  making  a  digital  examination,  with  the  pa- 
tient in  the  lateral  position,  one  should  insert  the  finger 
as  high  as  possible,  and  then  sweep  it  from  side  to  side, 
completely  encircling  the  rectum  on  its  withdrawal,  when 
the  polypi  will  be  discovered,  usually  just  above  the  inter- 
nal sphincter.  As  the  finger  is  withdrawn,  the  polypi  can 
often  be  brought  with  it,  outside  of  the  sphincter.  By 
means  of  proctoscopic  examination,  polypi  situated 
higher  in  the  rectum  may  be  discovered. 

Treatment. — In  the  treatment  of  polypi,  local  anes- 
thesia is  often  not  necessary.  They  can  be  snared  off  with 
ease  through  the  anoscope  or  proctoscope  with  little  or 
no  pain.  Where  the  polypus  is  situated  low,  so  that  it 
can  be  protruded  through  the  anus,  the  pedicle  may  be 
infiltrated  with  one-tenth  of  one  per  cent  solution  of 
eucain  or  chloretone,  transfixed  with  a  double  threaded 
needle,  and  the  pedicle  tied  off  in  two  sections  with  a 
double  ligature.  The  polypus  is  then  snipped  off  with  the 
scissors,  leaving  as  little  stump  as  is  possible.  It  is  prac- 
tically never  necessary  to  anesthetize  the  sphincter  and 
no  after-treatment  is  required. 

Hypertrophy  of  the  Anal  Papillae.  -  -  In  devoting 
some  space  to  the  anal  papillae,  the  author  has 
done  so  with  the  view  of  bringing  before  the  profes- 
sion a  condition  which  is  practically  never  recognized  by 
the  general  practitioner;  and  usually  overlooked  by  the 
general  surgeon,  who  includes  rectal  surgery  as  an  inci- 
dent in  his  practice.  It  is  one  of  the  many  minor  condi- 
tions which  originate  in  the  anal  canal  which,  while  never 
causing  such  serious  symptoms  as  to  endanger  health  or 


212  HYPERTROPHIED    ANAL    PAPILLAE. 

life,  or  to  cause  such  great  suffering  as  to  incapacitate  the 
patient  from  his  daily  occupation;  nevertheless,  is  of  no 
small  interest  to  the  medical  practitioner  because  of  the 
amount  of  discomfort  it  causes. 

This  may  only  amount  to  an  uneasiness,  hut  the  hyper- 
trophied  anal  papilla  is  often  responsible  for  symptoms 
ridiculously  out  of  proportion  to  the  size  and  severity  of 
the  lesion. 

Many  irregular  practitioners  who  hold  themselves  out 
as  "rectal  specialists,"  have  made  great  capital  out  of 
the  anal  papillae  and  have  attributed  to  them  the  causa- 
tion of  nearly  every  disease  in  the  calendar.  As  a  result, 
many  of  the  profession  have  gone  to  the  other  extreme, 
and  have  completely  ignored  the  existence  of  what  has 
been  proved  to  be  definite  diseased  conditions  of  definite 
anatomical  entities. 

When  a  patient  complaining  of  indefinite  rectal  or  anal 
symptoms  consults  his  physician,  too  often  he  is  dis- 
missed with  some  proprietary  ointment,  without  any  ef- 
fort being  made  to  locate  the  cause  of  the  trouble.  The 
special  study  of  the  Rectum,  with  its  allied  organs,  the 
Anus  and  the  Sigmoid,  has  brought  to  view  many  inter- 
esting conditions  which  have  been  overlooked  in  the  past ; 
and  it  is  with  the  view  of  clearing  up  some  of  the  obscure 
and  indefinable  symptoms  which  originate  in  the  region 
of  the  anus,  that  the  author  is  devoting  this  space  to 
Hypertrophy  of  the  Anal  Papillae. 

It  is  in  the  anal  canal,  where  most  of  the  pathological 
conditions  which  cause  pain  and  suffering,  and  reflexes 
without  number  originate.  Nature  has  been  unusually 
lavish  in  her  sensory  nerve  supply  to  these  organs,  and 
lesions  in  this  region  produce  referred  disturbances  in 


HYPERTEOPHIED    ANAL    PAPILLAE. 


213 


many  other  and  remote  organs.  When  one  considers  that 
the  anal  canal  measures  from  two-thirds  to  an  inch  and 
a  quarter  in  length  and  its  circumference  about  one  and 
one-quarter  inches  in  the  contracted  condition;  one  can 
readily  see  that  it  is  not  a  large  area  to  examine  and 
study,  and  diseased  conditions  in  this  region  should  not 
be  difficult  to  discover,  diagnose,  and  remedy. 


Fig.  93. 

Sectional  View  of  the  Anal  Canal  Showing  Hypertrophied  Anal  Papil- 
lae and  Crypts  of  Morgagni. 
C      Opening   of    Crypt   of    Morgagni. 
P.     Hypertrophied  papillae. 
N.     Normal  papilla. 


214  EXAMINATION    AND   DIAGNOSIS. 

The  anus  is  peculiarly  susceptible  to  injury  and  disease. 
First,  because  its  lining  membrane  being  neither  skin 
with  its  tough  resisting  power  nor  mucous  membrane 
with  its  generous  vascular  supply,  but  a  sort  of  transi- 
tional tissue,  neither  one  nor  the  other;  is  easily 
injured.  Secondly,  any  lesion  occurring  in  this  region  has 
a  small  chance  of  recovery,  because  of  its  meagre  blood } 
supply,  its  constantly  changing  position,  and  because  of 
trauma  and  infection  by  the  contents  of  the  bowel  which 
are  constantly  passing  over  it. 

In  order  to  understand  more  intelligently  the  condition 
under  discussion  it  might  be  well  to  say  a  few  words 
about  the  normal  anatomy  of  the  anal  papillae  (Fig.  92), 
These  papillae  occur  as  an  irregular  line  of  small  saw- 
tooth like  projections  encircling  the  point  of  the  juncture 
of  the  anus  with  the  rectum,  sometimes  called  the  linea 
dentata.  These  papillae,  varying  in  number  from  five  to  a 
dozen,  are  usually  situated  at  the  edges  of  the  semi-lunar 
anal  valves  or  crypts  of  Morgagni.  Andrews  considers 
these  papillae  the  normal  tactile  organs  of  the  rectum  and 
endowed  with  a  special  rectal  sense.  They  have  an  abund- 
ant nerve  supply,  which  accounts  for  the  many  reflex  dis- 
turbances which  originate  when  they  are  diseased. 

Examination  and  Diagnosis. — In  making  a  digital  ex- 
amination, unless  one  is  rather  expert,  these  papillae  are 
not  always  evident  to  the  touch,  but  are  apt  to  be  over- 
looked unless  an  ocular  inspection  is  made.  When  dis- 
eased, these  papillae  may  vary  in  size  from  a  quarter  of 
an  inch  in  length,  by  the  same  breadth  at  the  base,  to  an 
inch  and  a  quarter  or  an  inch  and  a  half  in  the  longest 
diameter.  (Fig.  93).  They  are  composed  largely  of  an 
over-growth  of  normal  tissue.  Often  by  everting  the 


DIAGNOSIS. 


215 


anus,  the  tips,  and  often  all  of  the  hypertrophied  papillae 
themselves  can  be  brought  into  view  (Fig.  94).  They  are 
of  a  pinkish  color,  slightly  paler  than  the  normal  mucous 
membrane  of  the  rectum. 


Fig.   94. 

Hypertrophied  Anal  Papillae. 

Drawn   from   a   photograph    of   one   of    the   author's   cases. 
This   well   shows   the   appearance   of   the    anal   papillae   when   the   anal 
margin  is  put  upon  the  stretch  by   strong  traction. 

A  distinguishing  point  between  hypertrophied  papillae 
and  polypi  in  the  fact  that  the  hypertrophied  papilla  is 
always  wider  at  its  base  than  the  apex,  while  the  polypus 
is  always  larger  than  the  pedicle  by  which  it  is  attached. 
The  polypus  is  usually  rounded  or  oval  in  shape,  while 
the  papillae  is  more  or  less  triangular,  or  ribbon  shaped. 
Enlarged  papillae  have  been  incorrectly  designated  as 


216  DIAGNOSIS. 


connective  tissue  piles.  They  never  show  the  character- 
istic varicose  appearance  of  the  internal  hemorrhoid  and 
are  attached  at  the  ano-rectal  line. 


Fig.  95. 

Proctoscopic  View  of  an  Exaggerated   Case   of  Hypertrophied  Anal 

Papillae. 

Containing  some  erectile  tissue,  on  examination 
through  the  anoscope,  they  will  often  be  seen  to  stand 
out  at  right  angles  from  the  mucous  membrane;  giving 
the  anal  canal  at  this  point  somewhat  of  a  fringed  ap- 
pearance. (Fig.  95).  Many  a  surgeon,  when  he  can  dis- 
cover no  pathological  lesion  but  finds  a  tight  sphincter, 
overlooks  what  he  may  call  "little  tags  of  the  mucous 
membrane. ' '  These  are  very  frequently  the  cause  of  the 
tight  sphincter;  for  let  it  be  said  here  that  no  sphincter 
is  abnormally  tight,  unless  there  is  some  pathological 


SYMPTOMS.  217 

lesion  causing  it;  and  a  simple  divulsion  of  the  sphincter 
will  not  relieve  the  symptoms,  as  many  a  surgeon  and 
patient  have  found  to  their  chargin  and  disappointment. 
Symptoms. — These  papillae  being  situated  on  the 
edge  of  the  Morgagnian  crypts,  are  pushed  and  dragged 
downward  during  the  passage  of  feces,  which  are  more 
firm  and  harsh  than  normal.  At  each  bowel  movement 
there  is  a  farther  pull  and  drag  on  the  papilla,  which  is 
gradually  .stretched  and  hypertrophied.  After  it  has 
become  sufficiently  hypertrophied  it  will  not  retract  at 
once  after  a  movement,  but  will  remain  in  the  grasp  of 
the  internal  sphincter,  causing  it  (the  sphincter)  to  con- 
tract. This  contraction  gradually  becomes  more  tonic, 
and  eventually  we  have  what  has  been  called  the  "tight 
contracted  sphincter."  This  gives  rise  to  one  of  the 
most  characteristic  symptoms  of  hypertrophied  papil- 
lae, or  that  of  an  unsatisfied  feeling  after  stool ;  a  feeling 
as  if  some  particle  of  fecal  matter  were  still  in  the  grasp 
of  the  sphincter  and  could  not  be  expelled.  Also  a  feel- 
ing of  irritation  and  uneasiness,  short  of  itching.  As  one 
patient  described  it  to  me,  "It  felt  like  the  bite  of  some 
small  animal,"  and  he  was  sure  that  he  had  a  tape  worm, 
because  he  ' '  could  feel  it  nibbling  at  the  anus. ' '  Another 
stated  that  it  felt  like  a  burr,  held  in  the  grasp  of  the 
sphincter.  This  feeling  can  be  immediately  relieved  by 
the  insertion  of  the  lubricated  finger  and  pushing  up  and 
replacing  the  enlarged  papillae  which  will  be  found  in  the 
grasp  of  the  internal  sphincter.  If  they  are  left  to  them- 
selves, it  will  often  take  from  fifteen  minutes  to  an  hour 
and  a  half  or  two  hours  for  them  to  gradually  retract; 
when  symptoms  will  entirely  disappear.  They  cause 
spasm  of  the  sphincter,  and  the  constantly  repeated 


218  CRYPTITIS. 

spasm  brings  on  a  hypertrophy  of  the  circular  muscular 
fibres,  forming  the  sphincter  muscles,  and  the  hypertro- 
phied  sphincter  is  the  so-called  'tight  sphincter." 

Another  symptom  which  the  hypertrophied  papillae 
cause  is  so-called  neuralgia  of  the  rectum,  being  trans- 
ferred and  transmitted  pains  from  pressure  on  the  nerve 
endings  of  the  papillae.  One  of  the  most  common  symp- 
toms, however,  for  which  hypertrophied  papillae  is  re- 
sponsible,  is  pruritus  ani.  I  do  not  wish  to  be  misunder- 
stood as  saying  that  hypertrophied  papillae  are  the  only 
cause  of  pruritus  ani,  because  the  causes  are  legion; 
but  it  is  a  common  and  probably  the  most  frequently 
overlooked  cause. 

Cryptitis.  It  will  be  remembered  that  each  papilla  is 
found  at  the  edge  of  the  semilunar  valve,  which  semilunar 
valve  is  the  outer  boundary  of  one  of  the  crypts  of  Morga- 
gni,  also  known  as  rectal  pockets  or  mucous  crypts.  These 
crypts,  whose  function  is  not  thoroughly  understood  as 
yet,  become  clogged  with  fecal  matter,  which  on  account 
of  the  shape  of  the  crypt  or  sac  is  not  readily  extruded. 
The  enlarged  anal  papilla  overlying  the  crypt  assists  in 
preventing  its  escape.  The  decomposition  of  this  fecal 
matter  or  retained  secretion  and  the  consequent  irrita- 
tion of  the  crypt,  sets  up  an  inflammation  or  cryptitis. 
which  may  go  on,  and  does  frequently,  to  pus  formation. 
The  accumulated  discharge  originating  here  overflows 
from  the  crypt,  and  as  it  runs  down  the  mucous  mem- 
brane of  the  anus,  sets  up  an  irritation,  which  is  made 
manifest  by  itching  or  pruritus,  and  the  moisture  com- 
plained of  by  many  patients  suffering  from  pruritus  will 
be  found  to  originate  from  this  cause. 


SYMPTOMS.  219 

The  feeling  of  uneasiness  following  stool,  which  some 
patients  complain  of,  is  unlike  that  produced  by  any 
other  condition.  It  has  been  described  to  me  by  one  pa- 
tient, as  a  feeling  as  if  he  had  thorns  or  pine  needles  in 
the  anus — a  sort  of  prickling  sensation — not  painful  but 
very  uncomfortable ;  and  he  would  find  himself  constant- 
ly shifting  from  side  to  side  as  he  sat  in  a  chair.  Occa- 
sionally the  shifting  would  relieve  him,  when  assisted  by 
some  pressure  on  the  anus,  thus  releasing  the  papillae 
from  the  grasp  of  the  sphincter. 

It  is  not  only  the  extremely  long  papilla  that  we  must 
look  for  to  cause  these  symptoms;  as  those  which  are 
only  half  an  inch  in  length,  the  tips  of  which  are  just 
engaged  in  the  sphincter,  are  sufficiently  long  to  cause 
symptoms. 

Another  condition  which  has  been  found  to  follow  the 
hypertrophy  of  an  anal  papilla  is  fissure-in-ano.  This  is 
caused,  as  has  been  demonstrated  by  "VVallis,  of  St.  Mark's 
Hospital,  London,  by  sufficient  pressure  during  stool  to 
tear  the  papilla  downward  from  the  edges  of  the  crypt, 
and  succeeding  stools  continuing  the  tearing  process,  the 
edge  of  the  crypt  is  brought  down  to  the  outside  of  the 
anus;  leaving  in  its  wake  a  raw,  ulcerated  furrow  (see 
Fig.  61),  which  is  split  open  further  by  each  stool,  and 
gives  rise  to  the  many  severe  and  intolerable  symptoms 
attending  upon  fissure  in  ano. 

Treatment. — The  treatment  of  this  condition  is  ex- 
tremely simple  and  consists  in  the  removal  of  the  papil- 
lae when  they  are  enlarged,  and  the  opening  and  cauteri- 
zation of  the  crypts  when  inflamed  or  infected.  Both 
conditions  are  present  together  so  often  that  their  treat- 
ment will  be  considered  together  as  well.  The  removal 

15 


220  TREATMENT. 

of  papillae  is  accomplished  in  the  following  manner :  The 
anoscope,  or  fenestrated  speculum,  is  inserted,  with  the 
opening  directed  towards  the  lowest  papilla  to  be  re- 
moved. The  papilla  is  injected  at  its  base  with  the  one- 
tenth  of  one  per  cent  solution  of  eucain,  or  half  of  one 
per  cent  of  chloretone,  and  distended  to  whiteness.  The 
papilla  is  then  removed  as  close  to  its  base  as  possible 
by  means  of  the  snare,  excision,  or  crushing.  It  is  never 
necessary  to  anesthetize  the  sphincter;  and  oftentimes 
the  anoscope  or  speculum  is  not  required.  By  eversion  of 
the  anus  (Fig.  94),  the  papilla  may  be  brought  into  view 
and  anesthetized  and  removed  while  thus  exposed. 

No  dressing  is  required;  the  hemorrhage,  which  is 
slight,  soon  ceases,  and  no  after-care  is  necessary,  other 
than  that  employed  following  the  operation  for  simple 
fissure. 

When  one  of  the  Morgagnian  crypts  is  inflamed,  the 
area  surrounding  the  crypt,  including  the  papilla,  should 
be  injected  and  distended  with  the  one-tenth  of  one  per 
cent  solution  of  eucain  and  a  V-shaped  incision  made  from 
above ;  the  base  being  at  the  extremities  of  the  crypt  and 
the  apex  one-half  inch  below  its  centre.  This  incision 
should  be  deep  enough  to  well  open  the  crypt.  The  flap, 
which  includes  the  papilla,  is  removed,  and  its  base  cau- 
terized with  chromic  acid,  which  has  been  previously 
fused  on  the  end  of  a  probe.  A  suppository  containing  two 
grains  each  of  chloretone,  thymol  iodide  and  powdered 
opium  is  then  inserted.  Where  more  than  one  crypt  is 
involved,  the  same  technique  is  employed  for  all ;  the  low- 
ermost crypt  being  operated  first,  and  the  others  injected 
in  turn  just  before  operating.  The  after  care  is  the  same 
as  has  been  described  for  hypertrophied  papillae. 


CHAPTER  XII. 

PROCTITIS  AND  SIGMOIDITIS. 

This  consists  of  a  catarrhal  inflammation,  either  acute 
or  chronic  affecting  the  mucous  membrane  lining  the  rec- 
tum, sigmoid  flexure  or  entire  colon.  There  are  many 
varieties  of  inflammation  affecting  the  rectum  and  sig- 
moid due  to  the  invasion  by  the  micro-organism  of  gonor- 
rhoea, syphilis,  diphtheria,  erysipelas  and  dysentery. 
With  the  exception  of  the  last  named  variety,  the  inflam- 
mation caused  by  the  micro-organisms  of  dysentery;  the 
other  varieties  accompany  or  are  caused  by  diseases  af- 
fecting other  organs  and  occur  as  a  complication,  and  will 
not  be  described  in  this  chapter.  Amoebic  dysentery 
will  be  discussed  fully  in  a  separate  chapter.  The  author 
therefore  will  limit  himself  to  discussion  of  simple  catar- 
rhal proctitis  and  sigmoiditis,  acute  and  chronic. 

Acute  Proctitis  and  Sigmoiditis. 

Etiology. — This  disease  occurs  at  all  ages,  children 
being  affected  as  frequently  as  adults.  Among  the  pre- 
disposing and  causative  factors  are  sudden  changes  in 
climate,  weather,  or  mode  of  living ;  the  ingestion  of  high- 
ly seasoned  foods,  condiments,  and  excesses  in  the  use  of 
alcohol  or  tobacco.  Constipation  is  occasionally  a  causa- 
tive factor,  but  the  presence  in  the  rectum  of  intestinal 
parasites,  impacted  feces  or  foreign  bodies  as  well  as 

221 


222  ACUTE   PROCTITIS ETIOLOGY   AND   SYMPTOMS. 

infection  of  the  rectum,  from  unclean  enema  tips  or  ex- 
amining instruments  are  more  often  responsible  for  its 
onset.  Patients  suffering  from  rheumatism  and  gout  or 
those  who  are  peculiarly  susceptible  to  sudden  chilling 
of  the  skin  surface  are  particularly  liable  to  attacks  of 
acute  catarrhal  proctitis.  Acute  indigestion,  with  its  at- 
tendant fermentation  of  food  products  in  the  intestinal 
tract  and  ptomaine  poisoning  are  very  prolific  sources 
and  inflammation  by  extension  from  any  acute  pelvic  dis- 
order is  not  uncommon.  The  use  of  drastic  cathartics  is 
also  an  etiologic  factor  of  no  small  importance,  and  the 
ingestion  of  many  food  articles  which  in  some  individ- 
uals, cause  urticaria  of  the  skin  surfaces,  will  often  be 
responsible  for  an  attack  of  acute  catarrhal  proctitis. 

Symptoms. — Its  onset  is  attended  oftentimes  by  a 
chill,  slight  rise  of  temperature  and  a  sense  of  uneasiness 
in  the  rectum  and  lower  abdomen;  oftentimes  accom- 
panied by  backache,  particularly  over  the  sacral  region, 
and  occasionally  shooting  pains  down  the  limbs.  This 
is  followed  in  a  few  hours  by  a  sense  of  fullness  and  heat 
in  the  rectum,  with  a  constantly  increasing  desire  for 
stool.  Disturbances  of  the  bladder  are  noted ;  particular- 
ly a  desire  to  urinate  frequently  and  a  burning  sensation 
when  doing  so.  The  patient  is  most  comfortable  lying 
on  his  side.  The  movements  become  soft  and  frequent 
evacuations  occur.  At  first  the  movements  are  those  of 
ordinary  diarrhoea;  after  the  first  day  or  so,  the  move- 
ments consist  more  largely  of  feces  mixed  with  mucous 
and  sometimes  tinged  with  blood.  If  the  disease  prog- 
resses and  ulceration  occurs,  the  movements  contain  blood 
and  pus,  and  a  muco-purulent  discharge  will  be  noted  at 
the  anal  orifice  between  movements  as  well.  In  children, 


ACUTE    PROCTITIS DIAGNOSIS    AND   TREATMENT.          223 

this  condition  frequently  brings  about  prolapse  of  the 
rectum,  and  occasionally  also  in  adults. 

Diagnosis. — With  the  history  of  an  onset  such  as 
has  been  given  above,  examination  of  the  rectal  cavity 
is  indicated.  With  the  patient  in  the  knee  shoulder  posi- 
tion the  proctoscope  should  be  inserted  and  the  rectum 
inflated.  If  the  insertion  of  the  proctoscope  is  accompa- 
nied by  considerable  pain,  as  it  will  be  in  many  cases 
suffering  from  proctitis,  the  sphincters  should  be  first 
anesthetized  according  to  the  technique  outlined  in  Chap- 
ter XV.  The  appearance  of  the  mucous  membrane  of 
rectum  is  somewhat  characteristic.  Upon  ocular  examin- 
ation, the  rectal  mucous  membrane  is  bright  red  in  color, 
its  appearance  being  not  unlike  the  appearance  of  the  in- 
flamed conjunctiva,  the  difference  being  that  the  rectal 
mucous  membrane  will  be  more  of  a  brick  red,  and  the 
mucous  membrane  appears  somewhat  velvety  and  oede- 
matous.  An  increased  quantity  of  stringy,  yellowish 
colored  mucous  will  be  noted.  The  blood  vessels  of  the 
rectal  wall,  and  particularly  on  the  valves  of  Houston, 
will  be  found  deeply  injected  and  clearly  outlined,  stand- 
ing out  distinctly  from  the  red  mucous  membrane. 

Treatment. — The  treatment  of  acute  catarrhal  proc- 
titis is  dietary,  systemic  and  local.  In  those  cases  de- 
pending for  their  origin  upon  the  presence  in  the  rectum 
or  sigmoid  of  impacted  feces  or  foreign  bodies,  their  re- 
moval is  first  indicated.  Where  the  proctitis  is  caused 
by  ptomaine  poisoning  from  decomposition  of  food  ma- 
terial in  the  intestinal  tract,  prompt  and  free  catharsis  is 
the  first  essential.  Patients  suffering  from  systemic  or 
constitutional  diseases  in  whom  the  proctitis  is  merely 
a  complication,  should  of  course  receive  general  medical 


224  ACUTE   PKOCTITIS LOCAL   TREATMENT. 

treatment  for  the  underlying  constitutional  or  systemic 
trouble. 

Where  irritating  or  improper  food  material  is  the  caus- 
ative factor,  or  the  indulgence  in  alcoholic  stimulants  or 
tobacco  to  excess  is  responsible,  their  interdiction  and 
withdrawal  is  obvious. 

In  the  local  treatment  of  acute  catarrhal  proctitis,  co- 
pious irrigations  of  the  rectum  sigmoid  and  colon  with 
normal  saline  solution,  at  a  temperature  of  110  to  115 
F.,  given  twice  or  three  times  during  the  twenty-four 
hours,  has  in  many  cases  been  sufficient. 

In  irrigating  the  colon,  the  position  in  which  the  best 
results  are  achieved  are  either  the  knee- shoulder,  left 
lateral  or  Sim's,  or  the  lithotomy.  Where  either  of  the 
latter  positions  are  employed,  the  hip  should  be  elevated 
considerably  higher  than  the  head.  The  irrigator,  or 
fountain  syringe,  to  be  placed  from  one  and  a 
half  to  two  feet  above  the  level  of  the  anus,  and  the  flow 
checked  by  pressure  on  the  tubing,  when  there  is  a  desire 
on  the  part  of  the  patient  to  expel  the  fluid  before  a  suffi- 
cient quantity  has  been  administered.  This  uncomfort- 
able feeling  is  due  to  the  over-distension  of  the  bowel  at 
certain  points  when  the  inflow  is  interrupted  either  by 
the  normal  sacculations  or  spasmodic  contraction  of  the 
circular  muscular  fibres.  This  sensation  will  soon  pass 
away,  however,  if  the  inflow  is  checked  for  a  moment  so 
as  to  allow  the  solution  already  in  the  bowel  to  flow  higher 
up.  Changing  the  position  of  the  patient  from  one  side 
to  the  other  and  massaging  the  abdomen  gently  will  great- 
ly assist  in  the  distribution  of  the  irrigating  fluid.  By 
this  method,  the  majority  of  patients  will  be  able  to  re- 


ACUTE  PBOCTITIS LOCAL  TREATMENT. 


225 


tain  a  sufficiently  large  amount  of  the  irrigating  fluid  to 
thoroughly  flush  the  entire  colon. 


Fig.  96. 

Spraying  the  Rectum  With  the  Patient  in  the  Knee- Shoulder 
Position. 

On  account  of  the  ballooning  out  of  the  rectal  cavity  by  air  inflation 
in  the  knee-shoulder  position,  this  position  is  ideal  for  the  application 
of  sprays  to  the  rectal  surfaces. 

In  those  cases  where  the  mucous  discharge  from  the 
rectum  or  sigmoid  is  profuse,  the  use  of  nitrate  of  silver 
solution  in  strengths  ranging  from  one  to  five  per  cent, 
by  means  of  the  rectal  spray,  has  been  found  very  effica- 
cious. The  author  uses  a  metal  spray  tube  attached  to 
the  hand  atomizer  or  used  with  the  compressed  air  tank, 
which  is  nine  inches  in  length.  Its  distal  extremity  is 
closed,  but  from  its  circumference,  about  one-sixteenth 
of  an  inch  from  the  end,  the  solution  issued  in  all  direc- 
tions from  four  small  apertures,  so  that  the  solution  is 
not  thrown  any  higher  into  the  bowel  than  one  wishes, 


226 


ACUTE  PKOCTITIS — TREATMENT. 


but  bathes  all  surfaces  alike  (see  Fig.  97).  The  rectum 
and  sigmoid  is  best  sprayed  with  the  patient  in  the  knee- 
shoulder  position  (Fig.  96).  In  some  cases,  where  the  mu- 
cous flow  appears  to  come  from  higher  up  in  the  bowel, 
irrigations  of  the  colon  with  various  astringent  solutions, 
are  indicated.  Two  to  five  per  cent  solutions  of  alum 
answer  very  nicely,  and  the  aqueous  fluid  extract  of  Kra- 
meria  from  five  per  cent  to  twenty  per  cent  as  advocated 
by  Tuttle,  has  proved  of  value  in  the  author's  hands. 


Fig.  97. 

Author's  Rectal  Spray  Tube. 

The  tip  being  closed  and  the  solution  issuing  from  its  circumference 
only,  it  is  impossible  to  throw  irritating  solutions  like  nitrate  of  silver 
higher  into  the  bowel  than  one  wishes. 

While  many  authors  advocate  the  confining  of  the  pa- 
tient to  bed  during  the  treatment  for  acute  catarrhal 
proctitis,  the  author  has  found  no  difficulty  in  securing 
results  by  allowing  the  patient  to  be  up  and  around  for  a 
greater  portion  of  the  day.  He  believes  that  better  drain- 
age of  the  intestinal  tract  is  secured  at  all  times  by  the 
upright  position.  In  some  cases  where  results  are  not 
obtained  by  spraying  with  aqueous  solutions,  and  where 


ACUTE  PROCTITIS TREATMENT. 


227 


there  is  a  tendency  for  the  bowel  walls  to  ulcerate  the 
insufflation  of  various  powders  will  be  found  of  great 
value— iodosyl,  compound  stearate  of  zinc  with  balsam 
peru  or  boric  acid,  thymol  iodide,  have  all  been  found 
very  satisfactory  in  these  cases. 


Fig.  98. 

DeVilbiss  Spray  Tube. 

Provided  with  an  adjustable  tip  so  that  the  spray  may  be  thrown  in 
any  direction. 

Ulcerating  spots  should  be  touched  up  with  pure  ich- 
thyol  or  solutions  of  5  per  cent  or  10  per  cent  of  nitrate 
of  silver.  The  author  is  not  in  sympathy  with  the  use  of 
solutions  of  the  stronger  chemical  antiseptics  such  as  the 
bichloride  of  mercury  or  carbolic  acid,  even  when  used  in 
very  weak  solutions;  he  believes  that  more  harm  is  ac- 
complished by  the  action  of  the  irritating  chemical  solu- 
tions on  the  weak  and  debilitated  lining  mucous  mem- 
brane, than  whatever  little  good  they  accomplish  by  their 
action  as  antiseptics. 

In  irrigating  or  flushing  the  colon,  the  recurrent  flow 
soft  rubber  colon  tube  devised  by  J.  L.  Jelks,  of  Mem- 


228  ACUTE  PROCTITIS TREATMENT. 

phis,  Tenn.,  will  be  found  a  very  useful  piece  of  appara- 
tus. For  the  technique  of  its  use  the  reader  is  referred  to 
the  following  chapter  on  dysentery.  During  the  treatment 
of  a  case  of  proctitis  or  sigmoiditis,  the  patient  should  be 
kept  on  a  light  and  unirritating  diet  in  which  the  vegetable 
elements  are  largely  eliminated.  The  thin  cereal  gruels 
prepared  from  oatmeal,  rice  and  barley,  egg  albumen,  the 
various  flavored  gelatines  and  liquid  peptone  solutions 
will  be  found  best  for  use  in  these  cases.  Milk  is  contra- 
indicated  on  account  of  its  tendency  to  constipate,  and 
the  fact  that  it  forms  hard  curds  which  only  further  irri- 
tate the  already  sensitive  bowel. 

Internal  medication  is  not  of  much  avail;  the  use  of 
ichthyol  in  2  to  5  gr.  doses  given  in  double  capsules  four 
times  daily,  the  author  believes  has  given  some  good  re- 
sults. He  has  found  the  employment  of  white  refined 
petroleum  oil  or  liquid  albolene  to  be  of  particular  value 
in  proctitis.  It  seems  to  have  a  specially  soothing  effect 
on  the  inflamed  and  irritated  mucous  membrane  of  the 
bowel  and  while  it  does  not  produce  or  stimulate  peristal- 
sis, it  causes  easy  and  free  evacuation  by  its  mechanical 
softening  and  lubricating  effect.  Being  a  mineral  oil  of 
no  food  value  and  having  no  medicinal  effect,  it  is  not 
acted  upon  by  the  digestive  secretions,  and  passes 
through  the  intestinal  canal  unchanged. 

The  patient  should  be  instructed  to  drink  six  to  eight 
glasses  of  water  daily;  if  there  i.s  any  doubt  as  to  the 
purity  of  the  water,  it  should  be  boiled  and  then  kept  in 
bottles  on  ice.  In  order  to  remove  the  flat  taste  of  boiled 
water,  the  author  would  suggest  that  before  use  it  be 
poured  into  an  open  vessel  or  pitcher  and  stirred  up  with 
a  revolving  egg  beater.  This  aereates  the  water  so  that 


CHRONIC  PROCTITIS  AND  SIGMOIDITIS.  229 

it  again  tastes  fresh  and  clean,  and  effectually  removes 
the  unpalatable  taste  which  is  one  of  the  drawbacks  to 
the  use  of  water  sterilized  by  boiling.  The  use  of  flax- 
seed  tea  is  often  of  assistance  in  these  cases.  If  properly 
prepared  is  of  distinct  value.  A  good  way  to  prepare 
flax-seed  tea  is  as  follows :  Take  four  or  five  tablespoons- 
ful  of  whole  flax  seed  and  place  in  a  shallow  pan.  Pour 
over  this  a  quart  of  boiling  water,  place  the  pan  over  the 
flame  and  allow  to  boil  for  five  minutes,  then  strain 
through  muslin  and  allow  it  to  cool.  It  is  best  kept  on  ice 
until  ready  to  use.  If  it  is  desired  to  sweeten  or  flavor 
the  flax-seed  tea,  lemon  juice,  oil  of  peppermint  or  winter- 
green  and  sugar  may  be  added  in  quantities  to  taste  while 
the  tea  is  still  hot.  A  teacupful  should  be  taken  as  hot 
as  can  be  comfortably  borne  every  night  at  bed  time.  This 
will  act,  often,  as  a  mild  cathartic  and  seems  to  have  some 
soothing  influence  on  the  mucous  membrane  of  the  bowel. 

Chronic  Proctitis  and  Sigmoiditis. 

This  disease  is  usually  of  two  varieties,  hypertrophic 
and  atrophic.  The  atrophic  variety  is  the  most  common 
variety  of  chronic  proctitis  or  sigmoiditis  met  with.  The 
hypertrophic  variety  may  follow  an  attack  of  acute  proc- 
titis or  sigmoiditis  but  is  often  produced  by  other  dis- 
eased conditions  outside  of  the  bowel.  Pressure  from  ab- 
dominal tumors,  movable  kidneys,  uterine  displacements, 
extension  from  pelvic  cellulitis  and  adhesions  following 
inflammatory  conditions  of  the  pelvis  may  all  set  up  at- 
tacks of  hypertrophic  proctitis  and  sigmoiditis.  Appen- 
dicitis has  also  been  mentioned  as  an  etiological  cause. 

The  atrophic  variety  may  often  be  brought  about  by 
a  long  period  of  chronic  constipation;  the  abuse  or  ex- 


230        CHRONIC  HYPERTEOPHIC  PROCTITIS SYMPTOMS. 

cessive  use  of  cathartics  extending  over  a  long  period  of 
time ;  excesses  in  both  eating  and  drinking,  particularly 
in  people  of  sedentary  habits.  Other  causes  of  a  more 
local  nature  are  repeated  attacks  of  fecal  impaction ;  the 
enema  habit,  foreign  bodies  in  the  rectum  and  unnatural 
practices. 

Chronic  Hypertrophic  Proctitis.  This  variety  is  dis- 
tinguished from  the  atrophic  variety  by  the  fact  that 
the  mucous  membrane  and  submucosa  are  always  thick- 
ened, and  the  glands  as  well  as  the  inter-glandular  con- 
nective tissue  hypertrophied  and  increased.  The  anal 
papillae  are  usually  very  much  enlarged  in  this  condi- 
tion. On  proctoscopic  examination,  the  appearance  of 
the  mucous  membrane  is  somewhat  characteristic.  Tut- 
tle  well  describes  it  as  follows:  "Through  the  procto- 
scope it  appears  oedematous,  paler  than  usual  and  cov- 
ered with  a  thin  coat  of  whitish  secretion.  The  swollen 
membrane  bulges  out  into  the  fenestra  of  the  conical 
speculum,  or  falls  down  and  completely  covers  the  end 
of  the  proctoscope.  When  the  muco-pus  is  wiped  off, 
the  membrane  presents  through  the  magnifying  glass  a 
cauliflower-like  appearance,  whitish  and  granular.  It 
does  not  bleed  easily,  and  the  end  of  a  fine  probe  being- 
pressed  down  upon  its  surface,  the  tissues  will  meet  to- 
gether above  it.  By  scraping  with  a  rectal  scoop  one 
may  obtain  a  certain  amount  of  muco-purulent  fluid,  con- 
sisting of  pus  cells,  leucocytes  and  various  bacteria,  to- 
gether with  small  masses  of  fecal  matter  and  undigested 
particles  of  food." 

Symptoms. — The  disease  may  be  of  insidious  onset, 
or  it  may  be  the  continuation  of  an  attack  of  acute  catar- 
rhal  proctitis.  The  patient  is  usually  in  a  run-down 


CHRONIC   HYPERTROPHIC    PROCTITIS DIAGNOSIS.         231 

condition,  and  presents  the  usual  symptoms  of  such  a 
state,  such  as  impaired  appetite,  foul  breath,  indigestion, 
gaseous  eructations,  diarrhoea,  occasionally  alternating 
with  constipation,  a  frequent  desire  to  move  the  bowels 
without  much  result  and  an  unsatisfied  feeling  as  if 
something  more  were  to  pass  away  after  a  stool.  Where 
the  bowels  are  loose,  the  stools  are  inclined  to  be  of  a  pea 
soup  consistency,  consisting  quite  largely  of  muco-pu- 
rulent  material,  or  there  may  be  small  hardened  boluses 
or  scybala  covered  with  sticky  mucus,  or  muco-pus.  On 
account  of  the  hypertrophied  condition  of  the  mucous 
membrane,  prolapsus  is  met  with  in  some  cases,  and 
pruritus  ani  is  a  frequent  symptom.  The  secretion  keeps 
the  region  of  the  sphincter  constantly  moist  and  is  oc- 
casionally so  profuse  and  constant  that  the  patient  has 
to  wear  an  absorbent  dressing  to  prevent  it  from  soiling 
the  clothes.  On  account  of  the  constant  moisture  of  the 
part,  condylomata  are  occasionally  found,  particularly 
at  the  posterior  aspect  of  the  anus  and  anal  canal. 

Diagnosis. — The  diagnosis  is  made  upon  proctoscopic 
and  sigmoidoscopic  examination.  The  characteristic 
hypertrophied  appearance  of  the  mucous  membrane,  with 
the  presence  of  muco-purulent  discharge,  with  or  with- 
out ulceration  of  the  mucous  membrane,  accompanied  by 
a  history  of  symptoms  such  as  have  been  given  above, 
should  make  the  diagnosis  not  difficult.  The  condition 
is,  fortunately,  not  very  common. 

Treatment. — If  upon  examination  of  the  patient  such 
extra-rectal  causes  as  appendicitis,  floating  kidney  or 
abdominal  or  pelvic  growths  impinging  upon  the  bowel 
are  discovered,  the  indicated  surgical  measures  for  their 
relief  should  be  carried  out.  The  patient's  dietary 


232      CHRONIC  HYPERTHROPHIC  PROCTITIS TREATMENT. 

should  be  corrected  and  all  condiments,  alcoholic  stimu- 
lants, pastries,  salads,  sweets,  fresh  fruits  and  freshly 
baked  foods  prohibited. 

In  order  to  give  as  little  work  to  the  intestines  as  pos- 
sible, the  patient  should  be  put  on  a  diet  which  is  largely 
assimilable,  such  as:  eggs,  the  various  gelatins,  lean 
meat,  poultry,  fresh  water  fish  and  small  quantities  of 
green  vegetables  such  as  spinach,  beet  tops,  lettuce,  en- 
dive and  kale.  The  patient  should  be  encouraged  to  drink 
large  quantities  of  cold  water  and  should  try  to  have  a 
bowel  movement  at  regular  hours.  Liquid  albolene  in 
doses  varying  from  one  to  four  drachms  three  or  four 
times  a  day  should  be  administered  on  account  of  its 
soothing  influence  upon  the  mucous  membrane  of  the 
intestinal  tract,  and  because  by  its  admixture  with  the 
f eces,  it  prevents  the  formation  of  hard,  irritating  masses. 

Where  symptoms  of  intestinal  indigestion  are  present 
the  author  has  found  pancreatin  in  ten-grain  doses,  tak- 
en with  or  directly  following  the  meal,  of  considerable 
value.  Ichthyol  in  double  capsules,  in  doses  of  from  two 
to  five  grains  four  times  daily  seems  to  be  of  some  serv- 
ice. The  bowels  should  be  flushed  morning  and  night 
with  some  astringent  solution  such  as  is  used  for  the 
treatment  of  acute  catarrhal  proctitis.  Tuttle  recom- 
mends very  highly  the  use  of  one  to  three  quarts  of  a  two 
to  ten  per  cent  solution  of  the  aqueous  fluid  extract  of 
krameria.  This  is  best  given  with  the  patient  in  the  knee- 
shoulder  position  and  through  a  Jelks'  recurrent  flow 
colon  tube.  The  preparation  of  the  aqueous  fluid  ex- 
tract of  krameria  as  described  by  Tuttle  is  as  follows: 

''Macerate  one  pound  of  bark  of  krameria  in  a  long 
percolating  tube  for  twenty-four  hours.  After  this  a 


CHRONIC  HYPERTHROPHIC  PROCTITIS TREATMENT.      233 

mixture  of  20  per  cent  glycerin  and  80  per  cent  water  is 
allowed  to  percolate  through  it.  The  percolate  should 
be  constantly  stirred  and  refiltered  through  the  bark  the 
second  time.  The  filtrate  is  then  evaporated  down  to 
one  pound,  thus  obtaining  an  aqueous  fluid  extract  con- 


Fig.  99. 

Ulcer  of  the  Rectum. 

This  case  well  illustrates  the  importance  in  proctoscopy  of  examining 
the  cavity  behind  each  rectal  valve.  In  this  patient  the  ulceration  was 
situated  on  the  right  lateral  wall  of  the  rectum,  and  had  not  the  first 
rectal  valve  been  pushed  aside  by  the  proctoscope  its  presence  might 
have  escaped  unnoticed. 


234         CHRONIC  ATROPHIC   PROCTITIS   AND  SIGMOIDITIS. 

taining  grain  for  grain  all  the  therapeutic  properties  of 
the  bark.  The  preparation  should  be  kept  in  a  dark  place 
and  not  exposed  to  the  air." 

If,  on  proctoscopic  or  sigmoidoscopic  examination  lo- 
calized ulcerated  areas  (Fig.  99)  are  discovered,  they 
should  be  sprayed  with  a  1  to  3  per  cent  solution  of  nitrate 
of  silver  or  5  per  cent  solution  of  ichthyol.  They  may  be 
stimulated  by  the  application  of  nitrate  of  silver  5  to  10 
per  cent  applied  with  a  long  handled  applicator  or  pure 
ichthyol  or  balsam  peru.  The  general  condition  of  the 
patient  must  be  improved  by  ordinary  tonic  measures 
and  the  encouragement  of  moderate  exercise  in  the  open 
air  and  sunshine. 

Chronic  Atrophic  Proctitis  and  Sigmoiditis. 

This  variety  is  more  common  than  the  hypertrophic, 
and  consists  of  a  general  atrophy  of  both  the  glands  and 
intra-glandular  structures  of  the  rectum  and  sigmoid. 
It  differs  from  the  hypertrophic  variety  in  that  it  does 
not  frequently  extend  higher  than  the  sigmoid  flexure 
and  there  is  a  thinning  or  destruction  of  the  mucous 
membrane  lining  of  the  bowel.  The  pathology  of  the 
condition  is  well  described  by  Tuttle  as  follows: 

''One  observes  upon  examining  the  mucous  membrane 
in  these  cases  an  irregular,  bosselated  or  granular  ap- 
pearance. The  surface  is  dry,  rough,  inelastic  and  with- 
out any  salient  vegetations.  Attached  to  the  surface  here 
and  there  are  small  masses  of  dry  fecal  material,  and 
occasionally  little  islands  of  necrotic  epithelium  or  pseu- 
do-membrane. 

' '  Microscopic  examination  shows  the  epithelium  absent 
in  many  places,  but  always  present  in  the  deeper  por- 


CHRONIC   ATBOPHIC   PROCTITIS SYMPTOMS.  235 

tions  of  the  crypts  of  Lieberkiihn.  These  follicles  are 
generally  atrophied,  the  intratubular  tissue  decreased, 
and  their  goblet  cells  are  few  in  number.  The  cylindrical 
epithelium  is  said  to  assume  the  stratified  pavement  type 
in  this  disease.  This  change  does  not  extend  more  than 
1  or  2  centimetres  above  the  ano-rectal  line;  it  is  con- 
fined to  the  superficial  structure  of  the  membrane,  and 
does  not  involve  the  tubules. 

"The  connective  tissue  of  the  submucous  coat  is  dense 
and  slightly  thickened;  it  does  not  contain  embryonic 
tissue  and  elastic  fibres,  as  in  the  hypertrophic  form.  The 
solitary  follicles  are  often  enlarged  and  distended.  At 
points  there  are  distinct  granulations,  and  ulcerations, 
accompanied  with  hyperemia  and  multiplication  of  the 
blood  vessels,  but  there  is  no  alteration  in  the  blood  ves- 
sel walls." 

Symptoms.  As  has  been  stated,  this  condition  super- 
venes frequently  on  an  old  long  standing  case  of  con- 
stipation. The  stools  are  small,  hard  and  dry,  and  their 
passage  is  painful;  they  are  often  streaked  with  blood, 
pus  and  mucous.  The  patient  suffers  from  tenesmus, 
referred  pain  in  the  sacral  region  and  down  the  legs. 
The  rectum  feels  hot  and  feels  after  stool,  as  if  it  were 
not  emptied.  This  feeling  is  not  like  the  sense  of  full- 
ness which  is  more  characteristic  of  the  hypertrophic 
variety;  but  more  a  sense  of  uneasiness  which  focuses 
the  patient's  attention  upon  the  rectum,  which  makes 
him  feel  that  the  emptying  of  the  rectum  will  bring  him 
relief.  Pruritus  ani  is  a  frequent  symptom  as  well  as 
spasm  of  the  sphincters.  On  account  of  the  contracted 
condition  of  the  anal  canal,  the  passages  are  frequently 
followed  by  the  production  of  small  fissures  or  cracks 

16 


236  CHEONIC  ATROPHIC  PEOCTITIS TREATMENT. 

in  the  mucous  membrane.  Their  presence  adds  a  sting- 
ing or  burning  sensation  to  the  other  symptoms  of  the 
disease.  These  fissures  are  very  superficial  and  are 
not  to  be  confounded  in  any  sense  with  the  true  or  typi- 
cal fissure  in  ano.  They  consist  merely  of  linear  abras- 
ions in  the  lining  membrane  of  the  anal  canal,  and  lack 
any  tendency  to  chronicity  which  is  characteristic  of  a 
true  fissure.  Hemorrhoids  are  said  to  be  found  fre- 
quently accompanying  this  condition. 

With  the  patient  in  the  knee- shoulder  position,  procto- 
scopic  examination  shows  the  mucous  membrane  to  be 
reddened  but  not  markedly  as  in  the  acute  variety;  dry, 
and  covered  here  and  there  with  small  flecks  of  dry  fecal 
matter.  The  insertion  of  the  proctoscope  is  usually  ac- 
companied by  some  hemorrhage  due  to  the  passage  of  the 
instrument.  On  examination  of  the  rectal  walls  num- 
erous pin  point  ulcerations  are  met  with.  The  mucous 
secretion  which  is  very  slight  in  this  condition,  clings 
to  the  bowel  wall,  and  is  characterized  by  thickness  and 
tenacity.  In  this  condition  the  mucous  membrane  does 
not  fall  together  before  the  proctoscope  and  the  rec- 
tum gives  the  appearance  of  being  a  stiff  tube,  while  the 
rectal  valves  stand  out  very  markedly.  Ulcers  other 
than  the  pin  point  variety  are  not  uncommon,  and  tend 
to  become  chronic  and  to  gradually  encircle  the  bowel, 
producing  a  strictured  condition. 

Treatment. — In  this  condition  the  presence  or  ab- 
sence of  syphilis  should  be  ascertained.  Where  either 
from  the  ignorance  of  the  patient  of  his  true  condition 
or  from  his  reticence  about  the  matter  one  cannot  obtain 
a  definite  history,  the  Wasserman  test,  or  serum  diag- 
nosis should  be  resorted  to.  If  positive,  the  ordinary 


CHRONIC  ATROPHIC  PROCTITIS TREATMENT.  237 

measures  for  the  treatment  of  syphilis  in  the  third  stage 
should  be  employed.  The  diet  is  exactly  the  same  as 
that  outlined  for  hypertrophic  proctitis,  with  the  ex- 
ception that  the  patient  may  have  fatty  food,  bread  (not 
freshly  baked),  toast,  rice,  sago  and  custards.  Where 
intestinal  indigestion  is  present  pancreatin  should  be  ad- 
ministered and  liquid  albolene  given  as  outlined  in  the 
treatment  of  the  hypertrophic  variety.  As  this  condi- 
tion is  usually  confined  to  the  rectum  and  lower  sigmoid, 
the  high  irrigations  will  not  be  necessary,  but  the  solu- 
tions mentioned  are  equally  applicable  for  the  flushing 
of  the  sigmoid  and  rectum  in  this  variety.  After  irrigat- 
ing the  rectum,  the  patient  should  be  put  in  the  knee- 
shoulder  position  and  under  the  guidance  of  the  eye,  ul- 
cerated patches  on  the  mucous  membrane  should  be 
touched  up  through  the  proctoscope  with  2  to  5  per  cent 
solution  of  nitrate  of  silver,  iodine  or  pure  icthyol.  Icthy- 
ol  in  5  per  cent  aqueous  solution  is  very  valuable  as  a 
spray  in  this  condition,  as  is  the  fluid  extract  of  kram- 
eria  in  strength  ranging  from  20  to  30  per  cent.  The 
treatment  of  the  accompanying  conditions  such  as  fis- 
sures, hemorrhoids  and  pruritus  should  be  carried  out 
as  outlined  under  the  respective  chapters.  What  has 
been  said  before  regarding  exercise  and  fresh  air  is 
equally  applicable  in  this  condition. 


CHAPTER  XIII. 


DYSENTERY. 

By  JOHN  L.  JELKS,  M.  D.,  Memphis,  Term. 

Synonyms. — Colitis,  Ruhr  or  Dysenteric  (German), 
Difficultas  Intestinorum  (Latin),  Au?  evrcpov  (Greek). 

Definition. — An  acute  or  chronic  inflammatory  dis- 
ease, usually  affecting  the  large  intestine,  beginning  in 
the  rectum  but  sometimes  extending  into  the  small  bowel. 
In  the  acute  form  it  is  characterized  by  pain,  tenesmus, 
and  frequent  passages  of  bloody  mucus.  In  the  chronic 
form  the  patient  suffers  recurring  attacks  of  diarrhoea 
alternating  with  constipation. 

Historical. — Dysentery  was  one  of  the  best  known 
diseases  of  antiquity.  Even  before  the  time  of  Hippo- 
crates, reference  to  it  was  made;  the  earliest  being  that 
found  in  the  papyros  of  Ebers'.  Hippocrates,  in  the  year 
460  B.  C.,  was  the  first  writer  to  give  a  fairly  accurate 
description  of  its  symptomatology,  pathology,  and  se- 
quellae. 

Other  well  known  writers  were  Celsus,  the  medical 
Cicero  of  his  day  (45  A.  D.),  Aretaeus,  Galen,  and  Alex- 
ander of  Tralles.  Then  for  more  than  a  century  little 
further  knowledge  was  imparted  until  the  time  of  Antonio 
Benivieni  (1506),  and  Thomas  (1833),  who  refuted  many 
of  the  erroneous  ideas  of  his  predecessors.  Woodward 

238 


DYSENTERY GENERAL    ETIOLOGY.  239 

(1879)  gave  a  most  excellent  history  of  this  disease  (Med- 
ical and  Surgical  History  of  the  War  of  the  Rebellion, 
Vol.  2).  Kartulis,  in  Egypt  (1885),  Flexner  (1890),  Coun- 
cilman and  Lefleur  (1892),  Shiga  of  Japan  (1897),  Strong 
and  Musgrave,  and  Harris,  of  Atlanta,  of  the  present 
era,  have  contributed  perhaps  the  most  valued  writings. 
Osier,  Tuttle,  and  Surgeon  General  Sternberg  of  the 
United  States  Army  are  also  among  those  who  have  fur- 
nished valuable  data  in  our  own  country. 

The  writer  of  this  chapter  has  also  made  close  study  of 
this  disease  in  the  Southern  States. 

Geographical  Distribution. — Dysentery  does  not  re- 
spect any  country,  climate  or  race.  Ayers  very  truthfully 
states,  that,  where  man  is  found,  there  some  of  its  forms 
appear.  A.  Hirsch  says  it  had  a  wide  distribution  over 
the  inhabited  earth  at  all  historic  times.  It  is  without 
doubt  one  of  the  four  great  epidemic  diseases  of  the 
world.  In  the  tropics  its  ravages  have  been  most  deadly, 
destroying  more  lives  than  cholera,  and  to  the  armies  it 
has  been  more  destructive  than  powder  and  shot  (Osier). 
Dysentery  is  a  destructive  giant  compared  to  which 
strong  drink  is  a  mere  phantom  (McGregor).  The  worst 
outbreaks  occur  as  endemics  in  the  tropics  and  decrease 
as  we  leave  this  latitude,  while  in  the  higher  latitudes  it 
seldom  appears  in  this  type,  though  now  and  then  in 
greater  or  less  epidemics.  A  very  striking  fact  relative 
to  this  affection  is  that  it  involves  the  cold  zones.  Epi- 
demics have  been  reported  in  Alaska,  Sweden,  Russia, 
Greenland,  and  Iceland,  also  others  of  the  colder  coun- 
tries. 

General  Etiology. — Season. — Among  the  predispos- 
ing causes  season  is  the  most  important.  More  cases  of 


240  DYSENTERY ETIOLOGY. 

dysentery  are  found  during  the  summer  and  autumn 
months.  This  is  due  to  several  reasons.  Sudden  changes 
in  temperature,  especially  sudden  rises,  have  a  most 
marked  effect.  It  is  most  prevalent  in  the  warm  cli- 
mates, and,  as  stated  above,  it  is  most  deadly  in  the 
tropics.  Therefore,  climate  should  be  mentioned  as  one 
of  the  causative  factors. 

Race. — Race  itself  does  not  seem  to  affect  this  disease. 
Strange,  though  it  may  seem,  the  negro  race  in  the  South 
has  not  seemed  to  suffer  much,  with  reference  to  this 
disease;  notwithstanding  the  baneful  consequences  of 
poor  hygienic  conditions  as  overcrowding,  improper  food, 
poor  ventilation,  filth,  thin  clothing,  and  especially 
syphilis — a  disease  almost  universal  among  this  race, 
either  inherited  or  acquired.  These,  however,  must  all 
be  included  under  predisposing  causes. 

Sex. — Under  etiology,  we  should  also  mention  sex. 
Within  our  experience,  which  is  not  at  variance  with  that 
of  other  writers,  dysentery  is  much  more  common  among 
males. 

Poor  Hygiene. — In  the  slums  of  our  cities,  where 
filth  abounds  and  where  proper  sewerage  is  lacking,  we 
find  more  cases  of  dysentery  than  in  the  sections  where 
the  hygienic  conditions  are  better.  Many  cases  are  found 
in  institutions  such  as  insane  asylums,  barracks,  jails  and 
army  camps.  Wherever  there  is  over-crowding,  there  is 
very  apt  to  be  found  a  large  percentage  of  dysenteric 
cases.  During  the  Civil  War,  Woodward  reported  259,071 
cases  of  acute  dysentery,  and  28,451  of  the  chronic  form, 
in  the  Federal  service  alone. 

Topography  and  Conditions  of  Soil. — Investigators 
have  tried  to  associate  dysentery  with  certain  topographi- 


DYSENTERY ETIOLOGY.  241 

cal  conditions,  or  with  conditions  in  the  soil,  but  have 
been  unable  to  do  so. 

Epidemics  have  proven  more  fatal  in  the  country  than 
in  the  city. 

Soil  that  is  badly  contaminated  with  dysenteric  ex- 
creta is  a  great  source  of  infection.  Czernicki  tells  about 
dysentery  breaking  out  in  two  French  squadrons  in  1875 
that  were  on  the  same  ground  occupied  a  short  time  pre- 
viously by  a  cavalry  regiment  which  had  been  affected 
with  the  same  disease. 

The  writer  has  often  found  nests  of  dysenteric  cases  in 
the  low  flat  mill  districts  of  the  city,  and  in  marshy  low- 
land sections  of  the  country.  No  doubt,  owing  to  the  char- 
acter of  the  soil  in  these  localities,  seepage  contamina- 
tion of  drinking  water  sources  sometimes  occurs.  Houses 
built  upon  a  low  damp  soil  are  unsanitary,  and,  when  the 
surrounding  soil  always  remains  saturated  with  moisture, 
there  exists  a  favorable  condition  for  the  development 
of  dysentery.  The  peculiar  emanations  from  soil  of  this 
kind  have  always  been  considered  very  harmful.  It  is 
thought  that  they  have  a  depressing  influence  upon  the 
inhabitants,  and  thus  make  easier  the  inroads  of  dis- 
eases. 

In  one  ill-drained  low  district  of  Memphis,  the  writer 
treated  six  cases  of  amebic  dysentery  within  a  radius  of 
two  blocks,  and  a  seventh  case  was  seen  that  had  been 
infected  in  the  same  territory  five  years  before.  It  is 
also  an  interesting  fact  to  note  here  that  two  families,  in 
which  were  four  of  the  patients,  purchased  vegetables 
from  the  same  Italian  huckster. 

There  is  yet  another  reason  why  we  find  more  cases  in 
the  marshy  low-land  districts.  Here  we  find  the  greatest 


242  DYSENTERY ETIOLOGY. 

growth  of  vegetation,  which,  when  conditions  are  favor- 
able, furnish  a  most  suitable  nidus  for  the  propagation 
and  development  of  amsbae,  bacteria,  and  other  micro- 
organisms. 

Foods. — Certain  articles  of  food  are  unquestionably 
predisposing  causes  in  dysentery.  This  fact  is  not  due  so 
much  to  an  idiocyncrasy  to  any  particular  foods,  but 
mainly  to  the  micro-organisms  which  they  contain,  and 
to  the  putrefactive  changes  which  occur  within  the  intes- 
tinal tract.  All  grounding  vegetables  and  fruits,  especi- 
ally those  shipped  from  the  tropics,  are  possible  sources 
of  infection. 

Undoubtedly  infections  with  the  amebae  have  been 
traceable  to  eating  such  vegetables  as  lettuce,  strawber- 
ries, cress  and  potatoes. 

Eating  food  in  excess,  and  the  resulting  attacks  of 
indigestion  often  pave  the  way  for  dysentery. 

Drinking  Water. — The  writer  has  given  much  thought 
to  water  supply  as  a  medium  through  which  dysenteric 
infections  are  conveyed.  This  is  undoubtedly  the  most 
common  source.  We  have  been  impressed  by  the  fact 
that  many  cases  are  found  among  sportsmen,  also  tim- 
bermen  who  spend  much  of  their  time  in  the  woods,  and 
who  drink,  when  necessity  requires,  from  surface  pools, 
springs  and  slashes. 

The  writer  has  treated  a  case  of  amebic  dysentery 
from  a  country  district  with  which  he  is  quite  familiar, 
and  has  knowledge  of  the  fact  that  the  disease  was  con- 
tracted in  the  same  infected  neighborhood  in  which 
twenty  years  previous  another  case  had  lived,  which 
proved  fatal.  The  fact  has  been  elicited  that  many  of 
the  writer's  cases  had  neighbors  suffering  in  like  manner, 


DYSENTERY — CLASSIFICATION.  243 

and  who  were  procuring  their  drinking  water  from  the 
same  source. 

There  are  certain  rivers  in  China  whose  waters  are 
known  to  cause  dvsenterv. 

•>  •* 

In  1863,  the  number  of  cases  among  the  workmen  con- 
structing the  Suez  Canal  was  decreased  when  the  better 
water  of  the  Nile  was  used. 

The  writer  has  treated  one  case  of  amebic  dysentery  in 
the  person  of  a  physician,  who  thinks  undoubtedly  that 
the  infection  was  obtained  from  drinking  Mississippi 
River  water  while  on  board  a  river  steamer.  Thevenol 
says,  "Nothing  is  so  prone  to  lead  to  disorganization  of 
the  large  intestine  as  infected  water."  Impure  water  itself 
does  not  produce  dysentery,  but  only  when  it  contains  the 
special  micro-organisms. 

Classification.— Acute  Catarrhal  Dysentery  or  Spor- 
adic Bacillary  Dysentery: 

This  form  is  the  least  severe  and  most  common  form 
that  is  encountered.  It  occurs  both  sporadically  and 
endemically.  This  type  is  characterized  by  the  frequent 
passage  of  great  quantities  of  mucus. 

Special  Etiology. — Children  principally  are  infected 
with  this  form,  but  we  often  see  it  in  adults,  most  often 
complicating  other  diseases.  It  is  the  kind  of  dysentery 
that  accompanies  all  of  the  exanthemata.  We  see  it  in 
fact,  complicating  almost  all  the  acute  infectious  diseases. 
Still  another  important  cause  is  the  ingestion  of  certain 
kinds  of  foods,  or  other  irritating  substances.  The  ordi- 
nary attacks  of  entero-colitis  in  babies  during  the  summer 
months  come  in  this  classification.  Most  of  these  attacks 
are  due  to  milk  poisoning. 


244  ACUTE  CATARRHAL  DYSENTERY. 

Pathology. — Macroscopically  a  superficial,  acute  in- 
flammation involving  the  large  intestine,  but  sometimes 
extending  into  the  small  bowel,  is  seen.  The  tendency 
of  such  cases  is  to  recover  without  necrosis.  Sometimes, 
though,  in  the  more  severe  attacks,  the  mucosa  will  be- 
come injected  to  such  a  degree  that  small  ulcerations 
occur.  In  these  cases  the  mucus  is  often  stained  or 
streaked  with  blood. 

Microscopically,  are  seen  the  bacillus  coli  communis, 
also  the  trichomonas  intestinalis,  and  paramoecium  coli, 
and  occasionally  the  cercomonas  intestinalis.  We  also 
find  red  blood  corpuscles  and  leucocytes,  and  always  large 
numbers  of  desquamated  epithelioid  cells,  dotted  about 
with  fat  globules  and  vacuoles. 

Symptoms. — The  onset  is  sudden  and  usually  ushered 
in  by  an  attack  of  cholera  morbus,  or  by  an  attack  of 
acute  indigestion.  Sometimes  a  more  or  less  distinct 
chill  may  occur  at  the  onset. 

Nausea  and  vomiting  are  not  rare  symptoms. 

The  tongue  has  a  moist  coat  at  first  but  soon  becomes 
dry. 

From  the  first  there  is  diarrhoea.  Pain  is  complained 
of  over  the  entire  abdomen,  also  tenesmus,  and  severe 
griping  pains.  The  patient  is  extremely  restless  and 
can  not  get  relief  from  a  desire  to  stool.  The  bowel 
movements  are  at  first  free,  and  watery,  or  sero-sanguin- 
ous,  but  later  on,  contain  only  small  quantities  of  mucus 
streaked  or  stained  with  blood,  and  have  an  offensive 
odor. 

A  slight  elevation  of  temperature  usually  accompanies 
this  form,  but,  in  more  severe  cases,  it  may  reach  103 


DIPHTHERITIC    DYSENTERY.  245 

degrees  F.  There  is  corresponding  acceleration  of  the 
pulse,  and  the  patient  complains  every  few  minutes  of 
thirst. 

The  stools,  during  the  first  day  or  two  of  the  attack, 
contain,  in  addition  to  the  above  mentioned  materials, 
small  fecal  masses  (scybala).  Sometimes  during  the 
course  of  the  attack,  the  stools  contain  an  excess  of  bile 
and  cause  intense  burning  while  passing. 

The  ordinary  cases  of  acute  catarrhal  dysentery  are 
self-limited,  usually  recovering  in  a  week.  Some  are  so 
mild  that  treatment  is  not  sought.  It  must  be  remem- 
bered, however,  that  the  cases  which  begin  with  mild 
symptoms  may  develop  graver  ones  at  any  moment. 

Diagnosis. — The  diagnosis  is  very  easy.  The 
cramping  pains,  tenesmus,  and  frequent  passages  of  mu- 
cus and  blood  are  positively  diagnostic.  If,  however,  a 
case  may  be  obscure,  the  microscope  and  proctoscope  will 
at  once  clear  it  up. 

Prognosis. — In  most  cases  the  prognosis  is  favor- 
able, but  it  is  best  to  be  guarded  at  all  times  in  giving  it. 
since  some  of  the  cases,  which,  at  first  seem  quite  mild, 
may  terminate  adversely.  Ordinarily,  though,  the  symp- 
toms will  subside  in  a  week,  and  the  patient  will  recover 
rapidly.  There  is  always  rapid  emaciation  and  weak- 
ness. 

Diphtheritic  Dysentery. 

Definition. — This  is  an  inflammation,  usually  confined 
to  the  lower  part  of  the  colon,  and  rectum,  but  sometimes 
extending  into  the  small  bowel.  It  is  accompanied  by  a 
croupous,  or  true  diphtheritic  exudation.  It  is  one  of  the 
epidemic  forms  found  in  Japan,  also  in  armies,  in  insane 


246  DYPHTHERITIC  DYSENTERY. 

asylums,  and  ships,  or  wherever  large  numbers  of  people 
are  crowded  together. 

Etiology. — This  form  of  dysentery  is  caused  by  the 
Bacillus  Dysenteriae,  discovered  by  Shiga  in  Japan 
(1897).  Flexner  and  Strong  encountered  the  same  bacil- 
lus in  one  of  the  forms  of  the  disease  which  prevails  in 
the  Philippines  and  Porto  Rico.  The  bacillus  is  described 
by  Shiga  as  being  a  short  rod  with  rounded  ends,  and 
closely  resembling  the  bacillus  of  typhoid  fever.  It  pos- 
sesses slight  motility.  Flexner  discovered  that  the  bacil- 
lus ' i  Is  inactive  to  blood  serum  from  typhoid  fever  cases, 
but  reacts  with  serum  from  dysenteric  cases  to  which 
bacillus  typhosus  does  not  respond."  Shiga 's  bacillus 
may  be  found  within  the  body  as  late  as  one  year  after 
the  primary  infection. 

Pathology. — The  mucosa,  if  the  attack  is  not  severe, 
is  coated  over  with  a  yellow  exudate.  Slight  ulceration  of 
the  mucous  membrane  over  the  tops  of  the  folds  of  the 
colon  are  seen. 

In  severe  attacks,  however,  all  the  layers  of  the  colon 
are  involved,  and  it  appears  greatly  enlarged.  The  in- 
filtration is  so  great  that  extensive  necrosis  takes  place. 
The  mucous  membrane  over  the  entire  colon  presents 
a  puffy  or  swollen  condition,  yellow  in  color.  Large 
areas  may  slough  en  masse. 

Microscopically,  this  slough  is  found  to  consist  of  a 
fibrinous  and  cellular  exudate  coating  over  the  mucosa. 

The  glands  of  Lieberkiihn  are  destroyed,  and  some- 
times no  trace  of  them  is  found. 

Symptoms. — The  symptoms  are  practically  the  same 
«ig  those  of  acute  dysentery  greatly  intensified.  The  on- 
set is  more  severe.  The  chill  is  often  present,  and  the 


SECONDARY   DIPHTHERITIC   DYSENTERY.  247 

fever  is  high,  running  an  irregular  remittent  course.  The 
pulse  is  greatly  accelerated,  tormina  and  tenesmus  are 
most  severe. 

Delirium  is  common.  Bowel  movements  may  at  first 
be  loose  and  watery.  Soon  great  quantities  of  sero-san- 
guineous  discharges,  containing  bloody  muco-purulent 
material  and  sloughs  of  variable  sizes  are  passed.  The 
distension  of  the  abdomen  is  greater  and  pain  is  more 
severe.  There  is  more  rapid  loss  of  strength. 

Diagnosis. — The  diagnostic  points  of  most  value  are 
the  character  of  the  dejections,  which  may  contain 
pseudo-membranes,  severe  symptoms,  and  the  appear- 
ance of  epidemics. 

The  positive  diagnosis  is  by  the  agglutination  test. 

Complications. — Complications  in  this  form  are  en- 
countered more  frequently. 

Perforations  sometimes  occur,  and  are  almost  inva- 
riably followed  by  peritonitis. 

Liver  abscess  is  another  grave  complication. 

Nephritis,  phlebitis,  pericarditis,  endocarditis,  and 
pleurisy  have  also  been  noted. 

Recovery  sometimes  takes  place,  but  usually  after  a 
more  or  less  chronic  course. 

Secondary  Diphtheritic  Dysentery. 

The  lesions  of  this  form  are  similar  to  those  of  the 
last  described,  but  not  so  severe.  The  secondary,  as  the 
name  implies,  usually  follows  one  of  the  acute,  or  chronic 
diseases,  as  pneumonia,  nephritis,  pericarditis,  endocar- 
ditis, pulmonary  phthisis,  typhoid  fever,  and  numbers  of 
other  varieties. 


248  AMEBIC  DYSENTEEY. 

Symptoms. — The  symptoms  are  sometimes  not  very 
noticeable.  The  griping  pains  and  tenesmus  are  not 
very  severe  as  a  rule.  The  patient  has  about  two  to  six 
loose  bowel  movements  a  day.  Anatomically,  the  inflam- 
mation is  very  superficial,  only  the  upper  layers  of  the 
mucosa  being  involved.  The  inflammation  may  progress 
producing  more  or  less  necrosis.  Very  little  blood  is 
found  in  the  stools. 

Prognosis. — The  patient  will  often  perish.  Owing 
to  adynamia  already  existing,  much  resistance  is  impos- 
sible. 

Amebic  Dysentery. 

Synonyms. — Amebic  colitis,  amebic  enteritis,  amebiasis. 

Dysentery  in  this  form  is  both  epidemic  and  endemic 
in  the  tropical  countries,  especially  India,  Africa,  and 
the  Philippine  Islands.  In  the  United  States  sporadic 
cases  are  met  with  frequently.  Osier  says,  his  cases  in  the 
Johns  Hopkins  Hospital  were  almost  exclusively  amebic. 
It  is  very  rare,  indeed,  that  the  writer  is  called  upon  to 
treat  a  case  of  the  severe  acute  or  chronic  type  in  which 
he  is  unable  to  make  a  positive  diagnosis  of  amebic  in- 
fection by  means  of  the  microscope. 

This  is  the  prevalent  type  of  the  grave  chronic  and 
relapsing  cases  of  dysentery  in  this  country,  and  many  of 
the  supposed  diphtheritic  dysenteries  are  of  this  origin. 
The  microscope  alone,  however,  can  verify  or  refute  this 
opinion. 

Etiology. — This  form  of  dysentery  is  caused  by  the 
entamoeba  histolytica  or  the  amoeba  dysenteriae  (Fig. 
100).  (Councilman  and  Lefluer.) 


AMEBIC   DYSENTERY ETIOLOGY. 


249 


It  is  a  type  of  protozoon,  unicellular,  and  motile,  sev- 
eral times  the  size  of  a  red  blood  corpuscle.    In  structure 


Fig.  100. 
Amoeba   Histolytica   Schaud. 

A,  young  specimen ;  B,  an  older  specimen  crammed  with  ingested  blood- 
corpuscles;  C,  D,  E,  three  figures  of  a  living  amoeba,  which  contains  a 
nucleus  and  three  blood  corpuscles,  to  show  the  change  of  form  and  the 
ectoplasmic  pseudopodia;  n,  nucleus;  b,  c,  blood  corpuscles. 

After  Jurgens,   from   Allbutt's    System   of   Medicine. 

the  organisms  have  an  outer  colorless  zone  called  the 
ectosarc  or  hyaloplasm,  and  an  inner  granular  zone,  the 
endosarc  or  endoplasm.  Its  nucleus  is  eccentrically  situ- 
ated, and  one  or  more  vacuoles  is  present.  This  parasite 
is  phagocytic  in  character,  and  may  be  seen  to  contain  red 
blood  cells,  vacuoles,  and  other  particles.  It  is  easily 
mistaken  for  a  large  epithelial  cell,  or  paramoecium,  when 
not  in  motion.  It  is  ten  to  fifty  microns  in  size.  The 
amoeba  hystolytica  multiples  by  segmentation,  the  nu- 
cleus and  endoplasm  dividing  in  such  manner  as  to  form 


250 


AMEBIC   DYSENTERY ETIOLOGY. 


several  embryo  cells  for  the  corresponding  number  of  new 
cells.  The  old  cell  either  dies  or  enters  into  the  encysted 
state.  After  an  uncertain  period  the  cell  wall  bursts,  and 
liberates  the  new  ones.  The  mother  cell,  containing  the 
daughter  cells,  may  remain  encysted  for  an  indefinite 


Fig.  101. 

Amoeba  Cell. 

A  and  B,  living  amoebae,  showing  changes  of  form  and  vacuolation  in 
the  protoplasm ;  C,  D,  E,  amoebae,  showing  different  conditions  of  the 
nucleus  (a);  F,  a  specimen  with  two  nuclei,  preparing  for  fission;  G, 
a  specimen  with  eight  nuclei  preparing  for  multiple  fission;  H,  an  en- 
cysted amoeba  containing  eight  nuclei ;  I,  a  cyst  from  which  young 
amoebae  (al)  are  escaping;  J,  K,  young  amoeba  free. 

After  Casagrandi  and  Barbagallo  from  Allbutt's  System  of  Medicine. 


AMEBIC   DYSENTERY ETIOLOGY.  251 

time.    In  this  state  it  is  much  smaller  than  the  ameboid 
form,  and  is  non-pathogenic. 

There  are  two  well  recognized  species  of  amebae,  the 
kind  above  described,  and  the  amoeba  coli  mitis  (Fig.  101) 
which  is  occasionally  found  in  healthy  persons.  This  or- 
ganism is  also  found  in  other  bowel  affections.  It  is  non-1 
phagocytic,  twelve  to  thirty-six  microns  in  size.  Propa- 
gation is  by  gemmation  or  budding;  a  portion  of  the  cell 
body  being  thrown  out  and  then  broken  off,  forming  a 
new  individual.* 

All  authorties  now  agree  that  the  bacteria  of  symbiosis, 
and  other  associated  micro-organisms,  have  much  to  do 
with  the  pathogenicity  of  the  amebae. 

I  have  noted  that  the  cases  presenting  themselves  dur- 
ing the  summer  or  autumn  usually  show  the  more  active 
and  phagocytic  amebae,  or,  more  properly  speaking,  in 
those  cases  in  which  I  have  found  the  more  active  and' 
phagocytic  amebae,  I  have  also  found  the  greater  viru- 
lence. In  making  microscopic  examinations  of  most  cases 
the  parasites  are  either  very  inactive  or  cease  motility 
quickly,  rendering  necessary  at  times  two  or  three  exami- 
nations to  make  a  positive  diagnosis.  In  most  cases  the 
bacteria  of  symbiosis  are  quite  numerous. 

The  amebae  are  introduced  into  the  intestinal  tract 
through  the  mouth  and  stomach,  but  the  acid  gastric 

*After   close   observation,  covering  a  great  number  of  cases,   the 
writer  has  become  convinced  that  there    exists    a    pathogenic    amel 
which    does   not   correspond   exactly  with  the  description  above  giver 
of  the  ameba  hystolitica. 

This  ameba  is  smaller,  the  hyaloplasm   is    not   so   distinct   thougn 
its  lighter  zone  is  discernable  and  this  hyloplasm   or   ectosarc  can   t 
seen   forming   pseudopods.     This  ameba  is  both  granular  and(  phago- 
cytic, and  is  often  observed  very  active,  hence  in  the  writer  s  opin 
ion    this    ameba  likewise   is    pathogenic. 


252  AMEBIC   DYSENTERY ETIOLOGY. 

juices  prevent  their  propagation.  They  pass  on  into  the 
colon  to  gain  lodgment  at  favorite  points,  namely,  the  ilio- 
cecal  valve,  hepatic  and  splenic  flexures,  and  especially 
upon  the  plicae  transversalis  recti.  In  most  cases  the  in- 
flammation begins  first  in  the  rectum  and  extends  upward 
by  continuity. 

The  writer  has  endeavored  to  explain  the  periods  of 
exacerbation  and  amelioration  of  symptoms,  in  the  fol- 
lowing ways : 

First. — The  entamoeba  hystolitica  is  especially  fond  of 
feeding  on  the  juicy  sub-epithelial  structures,  and,  in  a 
given  case,  this  particular  crop  or  generation,  within  the 
plentiful  surroundings,  may  become  indolent  and  easily 
satisfied,  and  also  less  active  in  the  process  of  sporula- 
tion. 

Second. — The  parasite  may  be  in  a  state  of  encystation, 
during  which  period  the  amebae  remain  dormant  or  non- 
pathogenic  until  finally  a  different  generation  produces 
a  more  active  and  phagocytic  type. 

Third. — Because  of  the  presence  of  a  greater  or  less 
number  of  bacteria  of  symbiosis  which,  in  the  light  of 
observation  of  most  authorties,  seem  essential  to  the 
activity  and  virulency  of  the  amebae. 

A  further  study  of  the  problems  of  immunity  may  in 
the  future  yield  information  which  will  be  of  paramount 
importance  in  amebic  dysentery,  both  in  reference  to  the 
amoeba  and  the  symbiotic  bacteria. 

This  disease  is  most  often  contracted  through  drinking 
water. 

Flies  and  other  insects  are  possible  means  of  transmis- 
sion. 

It  can  also  be  developed  through  contact. 


AMEBIC  DYSENTERY PATHOLOGY'.  253 

When  making  a  microscopical  examination  of  the  feces 
for  amebae,  the  following  will  be  helpful  to  the  inexperi- 
enced microscopist :  Technique:  Warm  the  slide  slight- 
ly. Secure  a  small  bit  of  the  mucus  from  the  stool  and 
place  upon  the  slide.  Cover  with  a  cover  glass  quickly, 
and  press  it  gently  until  the  material  is  thinly  distributed. 
Examine  at  once  with  the  one-sixth  or  the  oil  immersion 
objective.  This  should  be  done  as  rapidly  as  possible 
since  the  amebae  retain  motility  for  only  a  short  time  in 
temperatures,  much  lower  than  body  heat.  If  now  they 
can  not  be  found,  apply  warmth  by  holding  an  electric 
light  bulb  to  one  side  of  the  stage.  They  may  then  be  seen. 
Never  be  positive  that  the  amebae  are  not  present  though 
not  found.  They  may  be  in  a  state  of  encystation  in 
the  tissues,  and  only  after  an  acute  exacerbation  of  the 
disease,  will  they  be  found. 

A  still  better  plan,  and  the  only  accurate  way,  is  to 
examine  the  scrapings  of  the  ulcerated  mucous  membrane. 
This  method  should  always  be  practiced  when  possible. 

The  most  important  of  the  associated  organisms,  are 
the  streptococcus,  staphylococcus,  bacillus  coli  communis, 
trichomonas  intestinalis,  paramoecium,  cercomonas  in- 
testinalis,  lambia  intestinalis,  bacillus  pyocyaneus,  and 
others. 

Pathology. — Pathological  lesions  are  almost  always 
confined  to  the  rectum  and  colon,  but  occasionally  the 
ileum  may  become  involved. 

Appendicitis  is  quite  common. 

The  mucosa  appears  red  and  congested,  and  covered 
with  mucus  usually  tinged  with  blood. 

The  infiltration  and  edema  now  invade  the  submucosa. 
necrosis  of  the  overlying  mucous  membrane  takes  place, 


254 


AMEBIC  DYSENTERY PATHOLOGY. 


and  the  amebic  ulcer  is  formed.  This  necrosed  area  may 
be  oval  or  irregular  in  shape  and  appears  to  project  over, 
the  level  of  the  mucosa. 

The  amebae  gain  access  into  the  sub-mucosa  through 
the  inter-glandular  spaces  and  carry  with  them  the  asso- 


Fig.  102. 

Slough  of  Mucous  Membrane  Twenty-eight  Inches  in  Length  from  a 
Fatal    Case   of   Dysentery. 

Photograph  of  specimen  from  one  of  Jelk's  cases. 


AMEBIC  DYSENTERY PATHOLOGY.  255 

elated  organisms.  Here  they  set  up  an  active  inflamma- 
tion, and  produce  ecchymosis  and  swelling  of  the  glands. 
The  number  of  the  amebae  in  the  sub-mucosa  is  great, 
since  they  prefer  this  juicy  sub-epithelial  tissue,  no  doubt 
because  they  find  food  more  easily.  When  they  get  into 
the  sub-mucosa  their  presence  excites  a  reactive  inflam- 
mation at  once. 

It  is  important  to  note  here  that  the  bacteria  of  sym- 
biosis play  a  very  important  part  in  the  inflammation 
just  described.  Necrosis  now  takes  place  in  the  inflam- 
matory area  and  sloughing  follows.  In  grave  and  fatal 
cases  this  undermining  process,  so  to  speak,  may  become 
so  extensive,  and  the  congestion  so  great  that  large  areas 
will  necrose  and  slough.  The  writer  has  preserved  one 
specimen  of  this  character  twenty-eight  inches  in  length. 
(Fig.  102). 

The  muscular  coat  of  the  bowel  offers  greater  resist- 
ance to  the  amebae,  so  they  seldom  invade  it.  Occasion- 
ally, however,  this  undermining  process  will  extend  into 
the  intermuscular  tissue,  and  produce  the  same  results  as 
before  described.  In  this  way  the  larger  and  deeper  ul- 
cers form.  (Fig.  103). 

The  involvement  .of  the  rectum  in  one  case  was  so  ex- 
tensive that  the  new  scar-tissue  produced  an  almost  com- 
plete stenosis.  Higher  up  the  ulcerations  usually  cover 
a  smaller  area.  A  sharp-edged,  clean-cut  ulcer  results. 
This  ulcer  may  involve  the  greater  portion  of  the  thick- 
ness of  the  wall  of  the  bowel,  but  the  undermining  is  not 
so  extensive  and  the  thickening  which  results  lower  down 
is  not  so  marked  here.  One  post-mortem  revealed  nine 
distinct  perforations  in  the  splenic  flexure,  which  pro- 


256  AMEBIC  DYSENTERY PATHOLOGY. 

duced  sudden  death  when  the  loose  attachment  of  the 
omentum  was  broken  by  gaseous  over-distension. 


Fig.   103. 

Edge   of   Intestinal   Ulcer. 
(Toluidin-blue   and   eosin.      Beck    1    inch,    Oc.    3.) 

A.  Mucous  coat  which  projects  over  ulcer  at  f. 

B.  Submucosa. 

C.  Circular   layer   or  muscle   fibres. 

D.  Tissues  of  mesocolon. 

E.  Amoebae    in    dilated    lymph    spaces. 

Courtesy  of   Dr.   H.   F.    Harris,   Atlanta,   Ga. 

The  writer  wishes  also  to  call  attention  to  certain  spots 
and  lines  which  he  considers  almost  diagnostic  when  pres- 
ent. By  careful  examinations  with  the  proctoscope  small 
red  papular  spots  may  be  seen  dotted  about  among  the 
already  well  denned  ulcers.  Perhaps  on  the  following 
day  the  red  spots  will  show  a  little  white  or  yellow  point 
of  necrosis  in  its  center.  Upon  the  next  examination  an 
ulcer  will  be  seen  to  have  taken  its  place. 


AMEBIC  DYSENTERY PATHOLOGY. 


257 


In  another  instance  a  few  circinate  or  ring-worm-like 
lines  in  the  mucosa,  a  picture  which  is  not  observed  in 
other  forms  of  intestinal  infection,  will  be  seen.  These 


Fig.  104. 

Dysenteric  Ulceration  on  the  Valves  of  Houston. 

(After  Tuttlc.) 

lines  or  ulcers  are  chiefly  submucous,  but  sooner  or  later 
break  into  the  undermined  ulcer,  and  may  then  assume 
any  shape.  New  lines  will  form,  however,  to  tell  the 
story.  (Fig.  104). 

The  writer  has  also  observed  small  openings  at  points 
along  the  courses  of  these  circinate  lines  leading  to  ex- 
tensive submucous  ulcers.  At  other  times  the  intestinal 
mucosa  presents  only  a  few  circinate  lines  overlying  the 


258  AMEBIC  DYSENTERY PATHOLOGY. 

sub-epithelial  ulcers,  while  the  remaining  mucosa  pre- 
sents a  red  granular  appearance. 

In  a  few  cases  (unmistakably  amebic)  the  disease  ap- 
peared to  be  only  a  hypertrophic  proctitis,  or  a  procto- 
Isigmoiditis,  and  in  others  the  mucosa  appeared  puffy  or 
edematous. 

It  is  very  probable  in  my  opinion  that  some  of  these 
conditions  were  concomitant  and  due  to  associated  condi- 
tions, especially  collateral  infections. 

Amebae  have  been  found  free  in  the  peritoneal  cavity, 
and  in  other  parts  of  the  body,  especially  the  liver.  Here, 
;when  unassociated  with  collateral  organisms  the  para- 
sites are  non-pyogenic.  A  true  amebic,  unassociated  in- 
fection in  the  liver  would  mean  simply  that ;  and  not  an 
abscess  cavity  filled  with  the  most  offensive  pus,  as  is  so 
often  found.  Perhaps  in  almost  all  cases  amebae  have 
.been  conveyed  into  the  liver,  and,  but  for  the  fact  that 
they  were  unassociated  with  pyogenic  organisms,  ab- 
:scesses  would  surely  follow.  Hepatic  abscess  complicates 
probably  twenty  per  cent  of  all  chronic  amebic  infections, 
liowever,  exact  statistics  can  not  be  obtained. 

Councilman  found  this  complication  in  six  out  of  eight 
autopsies. 

Strong  and  Musgrave  in  fourteen  out  of  ninety-seven 
autopsies. 

Out  of  a  series  of  twenty-five  cases  treated  by  the  wri- 
ter in  1908,  four  were  complicated  by  hepatic  infections. 
In  two  of  these  cases  the  diagnoses  were  verified  by  ope- 
rations. In  one  a  large  abscess  of  the  right  lobe  was 
found,  and  in  the  other,  the  right  lobe  was  inflamed  and 
firmly  adherent  to  the  omentum  and  hepatic  flexure  of  the 


^^R*     ,4* 


PLATE    II. 

Section  of  intestine  just  below  ulceration.  Toluidin-blue  and  eosin. 
Beck  %,  Oc.  3.  In  upper  portion  of  the  field  a  large  vein  is  seen;  the  wall  of 
the  vessel  which  is  nearest  the  ulceration  is  being  infiltrated  with  small  cells 
and  is  breaking  down;  both  red  and  white  cells  and  amoebae  are  seen  within 
the  lumen  of  the  vessel.  In  the  lower  portion  of  the  field  many  amoebae  are 
seen,  some  in  the  tissues,  and  others  in  the  lymph  spaces  and  lymph  channel. 

Courtesy  of  H.  F.  Harris,  Atlanta,  Ga. 


AMEBIC  DYSENTERY SYMPTOMS.  259 

colon.  A  cholecystitis  was  also  present,  and  required 
drainage  for  six  weeks. 

The  infections  may  be  carried  into  the  liver  in  two 
ways : 

First,  and  most  probable,  .through  the  portal  vein, 
which  has  often  been  found  infected.  (See  Plate  II.) 

Second,  by  transmission  through  the  intestinal  wall. 

Craig  claims  that  the  kidneys  often  present  the  lesions 
of  acute  parenchymatous  nephritis. 

Symptoms. — In  the  more  virulent  or  malignant  cases 
the  onset  is  usually  sudden,  and  may  or  may  not  be  ush- 
ered in  with  a  rigor.  The  attack  is  preceded  by  a  period 
of  malaise,  often  accompanied  by  constipation.  An  at- 
tack of  acute  indigestion  often  precedes  this  form  of 
dysentery.  The  patient  may  have  six  to  forty  bowel 
movements  during  the  first  24  hours,  usually  sero-sangui- 
neous  in  character.  Prostration  is  early.  By  the  second  or 
third  day  considerable  blood  and  pus  begin  to  appear, 
the  latter  being  very  offensive  in  odor.  Prostration  in- 
creases with  the  further  absorption  of  toxins.  Tempera- 
ture usually  rises  to  102  to  103  degrees  F.,  and  is  of  the 
irregular  remittent  type.  Delirium  may  be  pronounced. 
General  abdominal  pain  and  tenesmus  with  tympanites 
and  tormina  are  prominent.  The  facies  abdominalis  de- 
note suffering  and  anxiety.  The  nose  is  pinched  and  the 
upper  lip  is  retracted,  and  the  condition  now  is  a  grave 
one.  The  thighs  are  flexed  upon  the  abdomen  and  legs 
upon  the  thighs  in  such  manner  as  to  relieve  pressure 
upon  the  abdominal  viscera.  Considerable  tenesmus  pre- 
cedes and  accompanies  all  bowel  movements  and  may  fol- 
low for  several  minutes,  though  as  a  rule  a  greater  or 


260  AMEBIC  DYSENTERY SYMPTOMS. 

less  relief  follows  the  passage  of  only  a  small  amount  of 
bloody  mucus.  Later  the  more  offensive  discharges,  con- 
taining greater  quantities  of  mucus,  pus  and  blood,  with 
perhaps  muco-fibrinous  casts,  or  mucous  membrane 
sloughs,  indicate  necrosis. 

The  above  symptoms  are  soon  followed  by  delirium, 
subnormal  temperature,  rapid,  feeble  pulse,  clammy  per- 
spiration, glazed  skin,  collapse  and  death.  If,  after  the 
sloughs  are  passed  the  patient  survives  the  sepsis  and  tox- 
aemia, and  healing  of  the  ulcers  follows,  the  process  is  a 
slow  one.  These  ulcers  are  finally  filled  with  granulation 
tissue  and  fibrinous  material,  which  contract,  causing 
more  or  less  stenosis.  The  symptoms  of  sepsis  and  tox- 
aemia from  the  absorption  of  necrotic  material  and  toxins 
very  gradually  diminish  until  the  patient  is  able  to  resume 
his  regular  occupation. 

The  following  case  reports  will  be  helpful : 
Case  1. — Name,   Dr.  -  -;   age,  36  years;   race, 

white;  occupation,  physician;  family  history,  negative; 
previous  state  of  health,  good,  until  six  months  previous, 
during  which  time  he  suffered  a  rapid  decline.  Symp- 
toms :  Lost  thirty  or  forty  pounds  in  weight ;  complained 
of  slight  colicky  pains  over  course  of  colon ;  troubled  with 
loose  fermentative  diarrhoea;  inactive  liver;  coated 
tongue;  temperature  992-5  F.;  pulse,  60;  skin,  dry  and 
muddy ;  slight  tenderness  on  pressure  over  cecum,  hepa- 
tic and  sigmoid  flexures;  pronounced  melancholia,  insom- 
nia, and  malaise  were  present.  Had  not  noticed  passages 
of  mucus  from  bowel  but  spoke  of  a  very  offensive  odor. 
Proctoscopy  revealed  a  considerable  quantity  of  san- 
gumo-purulent  mucus  in  the  rectum,  and  the  rectal  nm- 


AMEBIC  DYSENTERY SYMPTOMS.  261 

cosa  was  covered  with  same,  mixed  with  some  light 
brown  fecal  material.  Small  circinate  lines  and  punctate 
ulcers  were  seen  on  the  rectal  walls  and  valves  of  Hous- 
ton. A  mild  granular  procto-sigmoiditis  was  noted.  Mi- 
croscopic examination  revealed  entamoebae  histolyticae, 
phagocytic  and  associated  with  bacteria  of  symbiosis, 
trichomonas  intestinalis,  paramoecia,  and  others.  Diag- 
nosis, Amebic  Dysentery. 

Case  2. — Name,  Dr.  -  — ;  age,  53  years;  race, 

white;  occupation,  physician;  family  history,  negative; 
previous  state  of  health,  good,  until  23  years  of  age,  since 
which  time  he  has  never  been  well.  Symptoms:  At  the 
age  of  23  suffered  a  very  severe  attack  of  dysentery  and 
for  a  long  time,  hope  of  recovery  was  despaired  of.  Later 
a  change  of  climate  seemed  to  contribute  to  his  slow  but 
apparent  recovery.  After  returning  home  suffered  a  re- 
lapse. Since  that  time  has  suffered  abatement  and  accele- 
ration of  symptoms ;  alternating  attacks  of  diarrhoea  and 
constipation;  suffering  now  from  profound  melancholia 
and  insomnia  with  suicidal  inclinations.  Temperature, 
sub-normal;  pulse,  65;  tongue,  dry  and  coated  heavily, 
round  and  thick;  skin,  inactive  and  muddy;  liver,  en- 
larged, extending  three  inches  below  costal  border  and 
tender,  probably  the  seat  of  a  large  abscess.  Pain  on 
pressure  over  entire  course  of  colon,  especially  over  cae- 
cum, hepatic  and  sigmoid  flexures.  Furunculosis  (Sta- 
phylococcic)  over  entire  body;  atonia  gastrica  with  dilata- 
tion ;  kindeys,  normal. 

Doctor  William  Krauss'  report:  "Proctoscopy — rectal 
walls  very  much  thickened,  scarred  and  stenosed,  this 
latter  condition  observed  at  recto-sigmoid  juncture 


262  AMEBIC  DYSENTERY— SYMPTOMS. 

also;  red  granular  hypertrophic  recto-sigmoiditis.  The 
characteristic  ulcers,  previously  referred  to,  were  found 
beneath  a  coating  of  offensive  blood-tinged  mucus,  which 
was  mixed  with  pus.  Microscopic  examination  revealed 
large  active  phagocytic  amebae  histolyticae,  colon  ba- 
cilli, trichomonas  intestinalis,  cercomonas  intestinalis, 
and  other  symbiotic  bodies  in  great  numbers.  The  blood 
examination,  made  by  Dr.  Krauss  in  this  case  shows 
the  following:  3,940,000  red  cells,  75  per  cent  hemo- 
globin, 13,700  white  cells,  of  which  74  per  cent  poly- 
nuclears  and  3.3  per  cent  eosinophiles.  The  opsonic  in- 
dex failed.  The  bacteria  isolated  from  the  pustules  were 
staphylococcus  albus  and  a  single  colony  of  aureus.  I 
regard  the  blood  condition  to  be  one  of  secondary  ane- 
mia with  mild  coccus  infection,  and  the  moderate  eosino- 
philia  is  probably  due  to  the  intestinal  condition." 

The  furuncles  were  healing  nicely  when  I  last  saw  the 
patient,  and  he  expressed  himself  as  feeling  greatly  im- 
proved. 

Diagnosis,  Amebic  Dysentery. 

The  writer  looks  with  suspicion  upon  any  case  of  dys- 
entery or  diarrhoea,  recurring  or  relapsing,  which  has 
failed  to  respond  promptly  to  treatment. 

Dysentery  and  diarrhoea  are  not  essential  symptoms  of 
the  existence  of  amebiasis,  though  this  is  contrary  to  the 
generally  accepted  theory.  In  many  cases  the  patient 
will  complain  of  recurring  diarrhoea  which  has  existed 
for  months  or  years.  These  attacks  are  accompanied  by 
passages  of  mucus,  usually  considerable  in  quantity,  and 
occasionally  stained  with  blood.  The  patient  complains 
of  almost  constant  pain  or  discomfort  in  the  left  iliac 


AMEBIC  DYSENTERY COMPLICATIONS  AND  SEQUELAE.     263 

fossa,  and,  when  the  lower  rectum  is  the  seat  of  consider- 
able ulceration,  pain  at  the  end  of  the  spine  and  in  the 
rectum  is  felt.  This  symptom  is  momentarily  relieved  by 
evacuations-. 

A  case  from  the  Mississippi  Delta,  reported  by  me  to 
the  American  Proctologic  Society,  had  most  violent 
symptoms  from  the  onset.  On  the  fifth  day  a  large  slough 
of  mucous  membrane  (see  Fig.  102)  was  passed  en  masse 
Thirty- six  hours  later  the  patient  died. 

Most  of  the  chronic  cases  will  give  a  history  of  having 
lost  much  weight,  perhaps  twenty  to  fifty  pounds.  Many 
have  symptoms  of  interest  to  the  stomach  specialist,  and 
to  the  neurologist. 

Complications  and  Sequelae. — These  are  very  nu- 
merous indeed. 

Of  1537  cases  of  diarrhoea  in  Egypt  only  406  were  un- 
complicated. 

Hepatic  abscesses  were  found  in  six  out  of  eight  autop- 
sies by  Councilman.  In  four  of  these  they  were  multiple. 

Strong  and  Musgrave  found  hepatic  abscesses  in  14 
out  of  97  cases.  The  writer,  as  previously  stated,  found 
liver  infections  in  four  out  of  twenty-five  cases. 

The  vermiform  appendix  has  been  found  to  be  involved 
in  fully  ten  per  cent  of  chronic  cases  by  the  writer. 

Among  the  other  complications  most  frequently  occur- 
ring are,  perforations,  extensive  sloughs,  hemorrhages, 
fibrosis  of  the  valves  of  Houston,  rectal  stenosis,  adeno- 
mata recti,  cholecystitis  and  jaundice,  peri-rectal  abscess, 
hemorrhoids,  fistula,  pneumonia,  pulmonary  abscess, 
pleurisy,  bronchitis,  nephritis,  portal  thrombosis,  cere- 
bral and  meningeal  emboli,  gastritis,  atonia  gastrica,  mel- 


264  AMEBIC  DYSENTERY — DIAGNOSIS,  PROGNOSIS. 

ancholia,  which  is  often  profound,  and  in  two  recently 
treated  cases  extensive  skin  lesions  were  encountered.  In 
one  of  these  a  microscopic  examination  revealed  the  pres- 
ence of  the  staphyloccoccus  albus  and  aureus. 

Statistics  from  all  sources  show  that  perhaps  twenty 
per  cent  of  all  cases  are  complicated  by  hepatic  infection. 
The  right  lobe  is  most  often  involved. 

Perforations  may  occur  along  the  course  of  the  colon 
at  any  point  between  the  rectum  and  appendix.  Perf  ora- 
tive  appendicitis  has  been  noted. 

Perforation  occurred  in  85  out  of  580  cases  selected  by 
Beranger  and  Feraud. 

Stenoses  have  been  observed  in  a  large  per  cent  of 
chronic  cases,  usually  in  the  rectum  and  sigmoid.  When 
fibrosis  of  the  rectal  valves  is  observed,  it  is  a  grave  ob- 
stacle to  the  complete  cure  owing  to  interference  with 
drainage  and  local  treatment : 

Hemorrhoids,  though  frequently  noted,  are  not  serious 
complications  as  a  rule. 

The  other  complications  mentioned  above  should  be 
borne  in  mind  and  treated  when  they  occur. 

Diagnosis. — This  is  rendered  easy  by  means  of  the 
microscope,  all  doubt  being  removed  by  finding  the  en- 
tamoebae  histolyticae  in  the  stools,  or  in  the  material 
curetted  from  the  ulcers  in  the  rectum  and  sigmoid. 

Prognosis. — The  prognosis  in  amebic  dysentery  is 
likewise  much  graver  than  in  the  acute  catarrhal  form. 
It  may  be  said  to  depend  upon  several  things :  First — The 
previous  state  of  health  of  the  patient.  Second — The  hy- 
gienic condition  of  the  patient's  surroundings.  Third — 
The  efficiency  of  the  treatment  employed. 


AMEBIC   DYSENTERY TREATMENT.  265 

In  the  United  States  the  total  number  of  deaths  from 
all  forms  of  dysentery  in  1850  was  20,556,  a  per  cent  of 
6.32  of  the  total  mortality. 

In  1880  out  of  756,893  deaths,  10,825  were  from  dysen^ 
tery. 

Treatment. — The  treatment  of  dysentery  will  be  dis- 
cussed under  the  heads,  (a)  Prophylactic,  (b)  Dietetic, 
(c)  Eemedial  and  Operative. 

Prophylactic. — Strict  attention  should  at  all  times 
be  given  to  the  hygienic  condition  of  surroundings.  Re- 
move and  avoid  as  far  as  possible  the  causes  of  dysen- 
tery. Cases  should  be  isolated  when  it  is  possible  to  do 
so.  All  excreta  should  be  carefully  disinfected  and  de- 
posited where  the  water  supply  will  not  be  contaminated. 
The  country  practitioner,  living  where  there  is  no  sewer- 
age system,  should  never  neglect  to  caution  those  attend- 
ing the  patient  to  deposit  the  excreta  in  a  hole  dug  for  the 
purpose  as  far  removed  from  the  water  source  and  garden 
as  possible,  after  first  disinfecting  thoroughly. 

If  a  person,  knowing  the  danger,  were  to  deposit  the 
excreta  of  a  dysenteric  patient  in  a  garden,  it  would  be 
inexcusable.  The  writer  has,  however,  seen  this  done  by 
some  who  had  never  suspected  danger  in  so  doing.  In 
the  country,  and  in  small  towns,  without  sewerage,  little 
closets  are  usually  found  in  or  near  the  gardens,  and 
are  often  made  sources  of  fertilizing  material  for  the 
growth  of  vegetables.  It  is  the  duty  of  the  physician  to 
educate  his  patients  in  regard  to  all  dangers  resulting 
from  such  gross  unsanitary  pratices.  Wells  and  cisterns 
are  contaminated  much  more  often  than  the  average  lay- 
man suspects.  When  the  source  of  the  drinking  supply  is 


266  AMEBIC  DYSENTERY DIET. 

at  all  questionable,   the  water  should  be  boiled  before 
drinking. 

Over-crowding  and  poor  ventilation  should  be  pre- 
vented. The  care  of  the  room  occupied  by  the  patient  is 
important.  Unnecessary  furniture,  such  as  curtains, 
rugs,  carpets,  etc.,  should  be  removed.  Disinfectants 
should  be  used  at  regular  intervals.  Linen  should  be 
changed  daily.  Bed  pans,  commodes,  drinking  cups,  etc., 
should  be  disinfected  thoroughly. 

Diet. — Diet  is  as  important  as  any  other  matter  in  the 
treatment  of  dysentery.  During  the  period  of  acute  intes- 
tinal symptoms  it  should  consist  of  boiled,  or  perhaps 
better  still,  peptonized  sweet  milk,  buttermilk,  whey,  egg 
whites,  light  animal  broths,  peptonized  beef  juice,  barley 
water,  and  perhaps  one  of  the  standard  malted  milk 
foods  for  infants. 

In  all  cases  select  a  diet  which  is  digested  as  far  as 
possible  in  the  stomach,  and  which  has  little  waste.  Food 
is  best  given  at  intervals  of  one  to  two  hours  in  acute 
cases.  Plain  sweet  milk  may  be  diluted  with  barley  or 
rice  water,  lime  water  or  Vichy,  if  imperfectly  digested. 

During  convalescence  in  all  forms  of  dysentery  and  for 
chronic  cases,  the  writer  prefers  butter  milk,  peptonized 
or  pasteurized  sweet  milk,  whey,  and  eggs.  In  some  cases 
tender  portions  of  turnip  tops,  mustard,  and  spinach  have 
been  given,  and  were  relished  by  the  patient.  It  is,  how- 
ever, questionable  as  to  the  propriety  of  giving  the  pa- 
tient much  vegetable  diet. 

In  cases  of  amebic  dysentery  the  writer  is  especially 
partial  to  a  diet  of  milk  and  egg  whites.  The  eggs  may 
at  times  be  prescribed  in  large  quantities,  from  eight  to: 


AMEBIC  DYSENTERY — REMEDIAL  TREATMENT.  267 

fifteen  per  day.  They  can  be  ordered  raw,  mixed  with 
milk,  or  in  the  form  of  egg-albumen.  The  latter  is  made 
by  stirring  the  white  of  one  egg  into  a  glass  half  full  of 
crushed  ice,  then  flavor  with  orange  juice  and  sweeten. 
Diffusible  stimulants,  such  as  champagne,  sherry  wine, 
or  whisky,  may  also  be  added  to  the  egg  mixture  when 
cardiac  weakness  and  adynamia  are  present. 

The  albumen  may  also  be  mixed  with  sweet  milk,  or 
sweet  milk  with  lime  water  in  the  form  of  a  milk-shake, 
to  which  may  be  added  the  alcoholic  stimulants,  if  indi- 
cations exist. 

Butter-milk  is  an  especially  favorite  diet.  Its  acid 
properties  make  it  desirable. 

The  articles  of  diet  which  are  contra-indicated  are  all 
dishes  highly  seasoned  with  pepper,  cinnamon,  nutmeg, 
etc.  Vegetables,  especially  the  raw  varieties,  pork,  salt 
meats,  veal  and  fish,  saccharine  foods,  and  fried  foods, 
nuts,  oatmeal  and  fruits,  should  also  be  interdicted. 

Remedial.  The  medicinal  treatment  of  dysentery  is  a 
most  interesting  subject.  A  great  number  of  so-called 
specifics,  and  much  praised  remedies,  have  been  handed 
down  to  us,  but  most  of  them  have  proven  so  unsatisfac- 
tory that  it  is  no  surprise  that  most  of  the  present  day 
suggestions  are  greeted  with  a  certain  amount  of  skepti- 
cism or  personal  prejudice.  The  systemic  treatment  as 
a  cure  for  dysentery  is  erroneous.  It  is  a  local  disease 
and  therefore  requires  local  treatment.  This  is  certainly 
true  with  reference  to  immediate  pathology,  but  other 
remote  pathological  conditions  may  require  constitution- 
al treatment. 

The  ameba  is  a  very  low  form  of  organic  life  and  is 
very  easily  killed  or  rendered  inert.  The  fact  remains, 


268  AMEBIC  DYSENTERY REMEDIAL  TREATMENT. 

however,  that  the  parasites  are  embedded  in  the  tissues 
in  such  vast  numbers  as  to  make  their  destruction  diffi- 
cult. Certainly  any  chemical  which  is  given  by  mouth, 
after  passing  through  the  stomach  and  small  intestines, 
can  possess  little  parasitic  effect  when  it  reaches  the  low- 
er colon,  sigmoid  flexure,  and  rectum.  Therefore,  our 
chief  reliance  must  be  placed  in  local  applications,  which 
are  used  for  the  following  purposes,  namely:  That  of 
washing  away  the  pus,  mucus,  and  debris,  and,  at  the 
same  time,  the  amebae  and  other  pathogenic  organisms. 
Also  that  of  antisepticizing  the  bowel  contents  and  walls, 
that  the  further  growth  and  development  of  the  patho- 
genic organisms  will  be  inhibited. 

It  is  also  important  to  remember  that  the  remedies  se- 
lected should  be  those  which  will  destroy  the  greatest 
number  of  organisms  beneath  the  lining  membrane  of  the 
bowel  without  destruction  to  the  tissues  themselves. 

In  the  earlier  stages  of  acute  dysentery  the  patient 
should  be  put  in  bed  and  absolute  quiet  enjoined.  Chill- 
ing draughts  of  air  are  to  be  cautiously  avoided  since 
they  are  apt  to  increase  the  congestion  of  blood  toward 
the  internal  viscera.  Bathing  the  patient  with  warm 
water,  vinegar,  or  alcohol  will  often  give  great  comfort 
by  relieving  the  burning  sensation  in  the  skin.  The  peri- 
anal  region  should  be  sponged  frequently  with  an  anti- 
septic wash,  such  as  a  mild  boric  acid  and  formalin  solu- 
tion, and  dusted  with  some  mild  antiseptic  powder,  as 
equal  parts  of  boracic  acid  and  aristol.  An  ointment  of 
similar  composition  may  be  used  instead.  Application  of 
hot  or  cold  to  the  anal  region  will  often  relieve  the  burn- 
ing and  tenesmus  in  the  lower  rectum.  The  hot  hip 


AMEBIC  DYSENTERY TREATMENT LAXATIVES.  269 

baths  also  have  been  very  helpful  in  relieving  this  con- 
dition. 

In  the  more  severe  cases  the  constant  application  of 
ice  bags  over  the  left  iliac  region  gives  comfort.  Hot 
fomentations  are  sometimes  to  be  preferred  but  in  the 
majority  of  cases,  the  ice  bag  is  better. 

The  severe  griping  and  tormina  are  relieved  quite 
readily  by  hot  turpentine  stupes  or  by  large  flax  seed 
meal  poultices.  These  may  be  used  just  as  frequently  and 
for  as  long  a  period  as  needed. 

Laxatives. — Occasionally  absolute  rest  and  strict. diet 
are  all  that  is  needed  to  relieve  the  patient,  but  it  is  in 
most  cases  best  to  administer  some  mild  laxative  to  re- 
move the  contents  of  the  bowel,  which  act  as  both  me- 
chanical and  chemical  irritants. 

Castor  oil  and  magnesium  sulphate,  to  the  latter  of 
which  may  be  added  dilute  sulphuric  acid,  are  the  most 
popular  remedies  for  this  purpose.  The  salines,  by  their 
hydrogogic  action  deplete  the  inflamed  mucosa  and  wash 
away  many  of  the  infecting  micro-organisms.  It  must 
be  remembered,  however,  that  all  purgatives  act  as  irri- 
tants to  the  intestinal  mucous  membrane  in  a  greater 
or  less  degree,  and  their  use  must  be  guarded  with  judg- 
ment. In  some  cases  they  would  be  harmful.  If  there 
has  been  much  diarrhoea  and  the  stools  are  copious  and 
thin,  purgatives  are  contra-indicated. 

When  to  repeat  a  purgative  is  another  question  that 
should  be  considered  with  care.  Often  much  harm  is  done 
in  this  way. 

Calomel,  or  calomel  with  ipecac,  is  often  ordered  in 
small  doses  for  a  dry,  furred  tongue,  and  inactive  liver 


270  AMEBIC   DYSENTEEY LAXATIVES. 

with  foamy  acrid  discharges.  Our  aim  in  giving  calomel 
is  not  only  that  of  producing  the  antiseptic  action  of  bile, 
but  also  by  depleting  the  liver,  to  relieving  the  portal 
congestion;  and  this  in  turn,  the  congestion  of  the  veins 
about  the  rectum.  The  severe  griping  pains  and  tenes- 
mus,  the  diarrhoea,  and  restless  condition  of  the  patient, 
when  present,  must  be  relieved  or  the  outcome  will  be 
rapidly  adverse.  Opium  is  the  remedy,  either  in  the  form 
of  Dover's  powders,  paregoric,  laudanum,  or  morphine. 
This  last  is  no  doubt  the  most  popular  form  of  the  drug 
and  is  best  used  hypodermicaliy.  The  dose  should  be 
just  large  enough  to  keep  the  patient  quiet  and  to  relieve 
the  suffering  but  never  sufficient  to  produce  narcotism. 

It  must  not  be  forgotten  that  opium  may  do  great  harm 
in  some  instances.  If  nature  is  attempting  to  throw  off 
the  putrid  contents  of  the  bowels  in  large,  liquid  stools, 
we  should  not  give  opium,  for  in  so  doing  we  are  inter- 
fering with  her  efforts  to  relieve  the  condition. 

A  large  number  of  intestinal  antiseptics  have  been  giv- 
en internally  for  dysentery,  the  principal  ones  being  cal- 
omel, lead  acetate,  zinc  sulphocarbolate  (in  one-half  to 
three-grain  doses),  salol,  guaiacol  carbonate,  bichloride 
of  mercury  (dose,  grains  1-120—1-50),  and  acetozone. 
These  are  all,  however,  given  by  the  writer  with  a  cer- 
tain feeling  of  uncertainty. 

Those  cases  which  begin  with  symptoms  of  cholera 
morbus,  with  nausea  and  vomiting,  and  subnormal  tem- 
perature, call  for  hypodermic  injections  of  morphine 
sulph.  gr.  Vs,  and  atropine  sulph.  gr.  1-150.  To  control 
nausea  may  be  given  acid  carbolic  and  tr.  iodine,  of  each 
one  minim  well  diluted,  by  mouth.  This  is  followed  bv 


AMEBIC  DYSENTERY REMEDIAL  TREATMENT.  271 

calomel,  grs.  Vs-^A  and  salol,  grs.  2  to  5,  with  just  a 
sufficient  amount  of  hot  water  to  administer  same. 

In  other  cases  cocaine  hydrochlorate  (gr.  Vs-^)  may 
be  given,  and,  where  there  is  much  depression,  warm 
enemas  of  normal  salt  solution  may  be  given,  or  this  may 
be  given  by  hypodermoclysis.  The  effect  is  a  dilution  of 
the  toxines  and  a  reaction.  A  mustard  plaster  or  hot 
turpentine  stupes  over  the  epigastrium  are  beneficial 
in  these  cases.  If  the  temperature  and  pulse  are  not  sub- 
normal, the  tormina,  tenesmus,  and  burning  can  be  al- 
hiyed  by  enemas  of  cold  water,  the  temperature  of  which 
should  be  regulated  to  suit  the  case. 

When  there  is  marked  irritability  of  the  rectum,  the 
following  suppository  should  be  inserted  before  injec- 
tions are  made: 

J^     Cocaine  hydrochlorate, 
Ext.  stramonium, 
Ext.  belladonna — each  gr.  ss. 
01.  theobromae — Q.  S. 

M.  et.  ft.  in  suppositories  No.  1. 

Sig. — Hold  the  suppository  in  the  anal  canal 
about  one  minute,  then  press  into  the  rectum  with 
the  index  finger. 

Kartulis  claims  that  he  found  ipecacuanha  to  have  an 
almost  specific  influence  upon  dysentery. 

His  method  of  administering  this  drug  was  to  give  a 
one-half  grain  injection  of  morphine  hypodermically  and 
place  a  mustard  plaster  or  turpentine  stupe  over  the 
epigastrium.  After  half  an  hour  twenty  grains  of  pulv. 
ipecac  was  given,  and  this  dose  was  repeated  every  half- 
liour  to  one  hour  until  an  ounce  had  been  given. 


272 


AMEBIC  DYSENTERY INTERNAL  MEDICATION. 


Another  method  of  giving  this  drug :  Put  2  to  8  grams 
(l/2  to  2  drachms)  in  500  grams  (1  pint)  of  water  and 
let  stand  two  hours.  This  solution  is  filtered  off  and  con- 
stitutes the  first  dose,  or  this  is  at  times  divided  into  two 
or  more  doses.  According  to  Kartulis,  this  always  pro- 
duces emesis  and  diarrhoea,  but,  after  a  second  or  third 
infusion,  which  is  made  from  the  remaining  portion  of 
the  powder  with  the  same  quantity  of  water,  has  been  tak- 
en, the  vomiting  and  purging  become  less  frequent. 

If,  after  the  third  day's  treatment  with  these  infusions, 
the  patient  has  not  improved,  another  series  of  infusions 
with  a  fresh  supply  of  ipecac  should  be  given. 

The  writer  has  mentioned  this  treatment  only  to  con- 
demn it.  It  has  been  known  to  produce  death,  and  does 


Fig.  105. 

Instruments,   Etc.,  Required  in  the   Office   Treatment   of   Dysentery. 


AMEBIC  DYSENTERY INTERNAL  MEDICATION.  273 

not  cure  the  disease.  In  all  cases  it  is  a  cardiac  depres- 
sant and  lowers  the  physical  resistance  of  the  patient. 
It  is  a  violent  intestinal  irritant.  The  powdered  drug 
has  also  been  found  impacted  in  fatal  perforating  ulcers 
of  the  bowel.  To  my  mind,  therefore,  its  administration 
in  this  disease,  by  this  method,  is  dangerous,  adding  in- 
sult to  injury. 

For  the  acute  catarrhal  type  the  elimination  of  irritat- 
ing substances  and  free  exosmosis  obtainable  by  the  ad- 
ministration of  epsom  salts,  and  enjoined  rest  in  bed, 
with  abstinence  from  all  but  the  blandest  forms  of  diet, 
will  often  suffice.  In  these  cases,  however,  the  injection 
of  tepid  water,  containing  to  each  quart,  gtts.  x  to  xx 
of  formalin,  and  1  tablespoonful  of  boric  acid,  may  be 
necessary.  This  is  often  followed  by  the  same  quantity 
of  cold  water,  or  by  the  injection  of  1  or  2  ounces  of  olive 
oil  and  one  scruple  of  bismuth  subnitrate.  These  injec- 
tions can  do  no  harm  and  are  surely  destructive  to  the 
life  and  propagation  and  pathogenic  properties  of  the 
infecting  agent. 

If  the  symptoms  do  not  abate,  and  the  patient  does 
not  obtain  marked  relief  within  the  first  few  days  of 
the  use  of  the  above  described  treatments,  pathology  may 
be  present  which  may  require  other  forms  of  local  treat- 
ment in  the  nature  of  topical  applications. 

A  subacute  catarrhal  condition  may  supervene  in  which 
an  astringent  and  antiseptic  treatment  will  be  required  to 
complete  a  cure.  For  this  purpose  may  be  used  the  in- 
jection of  a  tannic  acid  solution,  one  drachm  to  a  pint 
of  water,  followed  by  the  introduction  of  a  suppository 
containing: 


274  J-AMEBIC   DYSENTERY LOCAL   TREATMENT. 

I?     Ext.  belladonna   grs.  V2 

Ext.  stramonium grs.  i/. 

Aristol   grs.     5 

Ol.  theobroma,  Q.  S. 

M.  et.  ft.  in  suppository,  No.  1. 

Or  the  following  ointment: 

I>     Ext.  belladonna grs.  y2 

Ext.  stramonium grs.  !/> 

Aristol    grs.     5 

Liquid  albolene,  Q.  S. 
M.  et.  ft.  in  ointment. 


Fig.   106. 

The  Jelks  Soft  Rubber  Recurrent  Recto-Colonic  Irrigating  Tube. 
Courtesy  of  Dutro  &  Hewitt,  Memphis,  Tenn. 

If  the  disease  assumes  one  of  the  more  virulent  types, 
and  if  the  ulceration  is  extensive,  still  more  radical  meas- 
ures should  be  sought  in  the  high  irrigation  with  the  for- 
malin boric  solutions.  These,  if  possible,  should  be  given 


AMEBIC   DYSENTERY — LOCAL   TREATMENT.  275 

through  a  recurrent  tube  (Fig.  106),  since  by  this  means 
only  can  a  large  quantity  of  the  solution  be  used  without 
distending  the  inflamed  and  ulcerated  bowel  to  a  painful 
or  perhaps  dangerous  degree. 

Four  to  eight  quarts  of  this  solution  are  usually  re- 
quired for  one  irrigation. 

Some  authorities  are  partial  to  the  use  of  quinine  so- 
lutions (1-5000  to  1-500)  in  cases  of  amebic  infections. 
Among  the  advocates  of  this  drug  are  Musgrave  and 
Strong,  and  Osier.  H.  F.  Harris,  of  Atlanta,  says :  "I 
used  this  treatment  with  great  persistence  in  some  of 
my  earlier  cases,  but  not  in  a  single  instance  was  there 
the  slightest  perceptible  result." 

"Injections  of  1-100  to  1-300  watery  solution  of  bi-sul- 
phate  of  quinine  were  somewhat  beneficial  in  one  or  two 
instances." 

My  own  experience  with  these  injections  is  in  accord 
with  that  of  Dr.  Harris. 

The  use  of  formalin  solutions  in  the  strength  of  1-500 
to  1-1000  have  in  the  writer's  hands  afforded  the  best  re- 
sults. 

My  study  of  the  effects  of  this  chemical  has  extended 
over  a  period  of  ten  years.  I  have  relied  not  only  upon 
clinical  results  obtained,  but  also  upon  the  microscopical 
observations  in  demonstrating  the  efficiency  of  formalin. 
After  only  one  or  two  injections  with  these  solutions  I 
have  been  unable  to  find  any  living  organisms  in  the  bow- 
els for  hours  afterwards. 

This  it  was  observed  was  not  the  case  when  other  so- 
lutions were  used. 


276 


AMEBIC    DYSENTERY LOCAL   TREATMENT. 


Eapid  healing  of  the  ulcers  was  always  noted  while 
continuing  the  irrigations  of  the  formalin  in  the  above 
mentioned  strengths. 

To  be  certain  of  the  effect  of  this  drug,  its  use  was 
discontinued  for  the  time  being,  and  such  irrigations  as 
plain  water  (warm  or  iced),  normal  salt,  and  quinine 
solutions,  were  substituted.  In  every  instance  the  ulcers 
reformed,  and  both  amebae  and  bacteria  of  symbiosis 
were  found  again  in  the  microscopical  examinations. 
Upon  returning,  however,  to  the  formalin  irrigations 
these  micro-organisms  disappeared  and  the  ulcers  began 
the  process  of  repair.  Thus  the  writer  has  concluded 
that  this  chemical,  judiciously  used,  is  really  the  most 
effective  in  the  destruction  of  the  amebae  and  associated 


Fig.   107. 

Exaggerated  Sims'  Position  Showing  Method  of  High  Irrigation  of 
Colon  Through  Jelks'  Recurrent  Tube. 


AMEBIC    DYSENTERY LOCAL   TREATMENT.  277 

organisms,  and  most  valuable  in  the  treatment  of  dys- 
entery. 

The  injection  of  olive  oil  and  bismuth  almost  instantly 
relieves  the  painful  effects  of  these  solutions. 

The  dangers  of  over-distension  of  an  inflamed  and 
ulcerated  colon  are  difficult  to  over-estimate.  To  avoid 
this  the  writer  has  devised  a  double  or  recurrent  colon 
tube,  made  of  soft  rubber,  and  constructed  in  such  man- 
ner as  to  facilitate  its  introduction  through  the  rectum, 
into  the  sigmoid  and  descending  colon.  The  tube,  hav- 
ing been  properly  inserted,  it  is  an  easy  matter  to  change 
the  position  of  the  patient,  and  by  so  doing  irrigate  the 
entire  colon.  (Fig.  107). 

In  some  instaiaces  the  tube  is  obstructed  by  the  rectal 
or  recto-sigmoid  valves,  which  may  necessitate  its  intro- 
duction through  the  sigmoidoscope  or  proctoscope.  In 
chronic  cases  especially  has  this  difficulty  been  encoun- 
tered, since  in  these  a  fibrinous  infiltration  of  these  struc- 
tures often  exists,  rendering- almost  impossible  the  use 
of  an  ordinary  rectal  tube.  To  ascertain  whether  or  not 
the  tube  has  coiled  in  the  rectum,  the  operator  can  intro- 
duce the  index  finger,  well  annointed,  with  the  lubricant 
given  below.  After  several  unsuccessful  attempts  have 
been  made  the  proctoscope  should  be  introduced  and  the 
tube  inserted  through  it,  as  is  shown  in  Fig.  108. 

A  lubricant  of  the  following  formula  is  preferred  by 
the  writer : 

K     Tragacanth  Powder   (Best)   grs.  384 

Phenol   m     240 

Glycerine oz.     2 

Aqua  Dist Q.  S.  ad.  qt.     1 


278 


AMEBIC    DYSENTERY— LOCAL   TREATMENT. 


M.  Sig. — Shake  up  gum  with  enough  alcohol  to  make 
thick  paste.  Add  acid  and  glycerine.  Shake  well  and  add 
water  all  at  once.  Agitate  vigorously. 


Fig.   108. 

Position  of  Patient  for  Proctoscopy,  Proctoscope  Introduced  to 
Facilitate  the  Introduction   of  the   Colon  Tube. 


CHRONIC  OK  SECONDARY  AMEBIC  DYSENTERY.  279 

Dr.  Louis  LeRoy,  of  Memphis,  lias  suggested  the  use 
of  phenol  sulphonate  of  copper  solutions  for  the  colon 
irrigations. 

The  writer  has  used  this  chemical  in  the  treatment  of 
a  number  of  cases  but  is  unable  to  state  its  exact  degree 
of  efficiency.  It  is  a  very  powerful  parasiticide  and  its 
use  is  advised  alternately  with  the  formalin  boric  solution. 
The  strength  of  the  copper  solution  is  8  to  10  grains  to 
each  quart  of  sterile  water. 

Ichthyol  (10%  solution)  applied  locally  to  the  mucous 
membrane,  or  gauze,  saturated  with  the  same  solution, 
packed  in  the  rectum,  has  seemed  to  exert  a  beneficial 
effect. 

It  is  well  to  mention  here  that  an  antidysenteric  serum 
has  been  very  highly  recommended  in  the  treatment  of 
the  malignant  bacillary  type  of  dysentery. 

Chronic  or  Secondary  Amebic  Dysentery. 

AH  sub-acute  or  chronic  cases  of  dysentery  depend  for 
their  symptoms  upon  an  ulcerated  and  inflamed  condi- 
tion which  will  not  yield  to  treatment. 

These  cases  have  exacerbations  and  amelioration  of 
symptoms.  They  often  complain  of  constipation,  which 
may  extend  through  a  period  of  weeks  or  even  months. 
It  is  in  these  sub-acute  and  chronic  cases  that  the  procto- 
logist  is  most  often  consulted. 

Such  remedies  as  nitrate  of  silver,  grains  30  to  60  to 
an  ounce  of  sterile  water,  or  a  20%  solution  of  argyroi 
are  applied  after  first  cleansing  and  antisepticizing  the 
rectum  and  sigmoid  with  pledgets  of  cotton  wrung  out  of 
hot  formalin'  boric  solutions.  (See  Fig.  109.) 


280 


CHRONIC  OP,  SECONDARY  AMEBIC  DYSENTERY. 


A  30%  solution  of  lactic  acid  has  also  been  used  to 
cauterize  the  ulcerative  areas. 


Fig.  109. 

Method  of  Application  of  Silver  and  Other  Solutions  to  the  Ulcerated 
Surfaces  of  the  Rectum  and  Sigmoid. 


CHRONIC  OK  SECONDARY  AMEBIC  DYSENTERY. 


281 


After  these  applications  have  been  made  the  bowel  is 
sprayed  with  some  neutral  or  alkaline  solution  to  neutral- 


Fig,  no. 

Method  of  Spraying  Rectum  and  Sigmoid,  With  Solutions  and  Also 
Insufflating    Mucous  Surfaces  With  Antiseptic  Powders. 


282  CHRONIC  OE  SECONDARY  AMEBIC  DYSENTERY. 

ize  the  excess  of  the  silver  or  other  solution  used.  (See 
Fig.  110.) 

The  bowel  surfaces  are  then  dried.  Now  the  insuffla- 
tion of  some  non-toxic  antiseptic  powder  such  as  equal 
parts  of  boric  acid  and  aristol  is  advised. 

The  symptom  of  iodism  is  an  unpleasant  one  and  may 
be  readily  produced  by  the  instillation  of  drugs  contain- 
ing iodine  into  the  rectum.  Because  of  this,  these  rem- 
edies, such  as  aristol,  bismuth-formic-iodide  and  iodo- 
form  have  appeared  most  effectual  when  used  just  to  the 
point  of  tolerance. 

When  the  amebic  infection  has  become  very  chronic,  or 
has  extended  into  all  parts  of  the  colon  beyond  the  use 
of  the  local  measures  just  described,  appendicostomy 
should  be  performed  and  the  same  irrigations  practiced 
through  the  appendiceal  stump.  The  water  is  allowed 
to  pass  out  through  the  rectum  into  the  catch  basin. 

This  plan  of  treatment  was  first  advised  by  Dr.  E.  A. 
Corsons,  of  Savannah,  Ga. 

In  1898  Dr.  H.  F.  Harris  stated  that  some  years  be- 
fore Dr.  Corsons  had  made  this  suggestion  to  him.  Irri- 
gations of  the  bowel  with  hydrogen  peroxide  through  the 
artificial  opening,  thus  established,  were  also  advised. 

About  the  year  1901  Dr.  Robert  Weir,  of  New  York, 
while  performing  a  colostomy  for  amebic  dysentery,  an- 
chored the  appendix  and  irrigated  through  the  stump 
with  a  saline  solution. 

Shortly  afterward  Dr.  Meyer,  also  of  New  York,  per- 
formed a  similar  operation. 

Dr.  Tuttle,  of  New  York,  conceived  the  plan  of  allow- 
ing the  appendix  to  remain  undisturbed  after  anchorage 


CHRONIC  AMEBIC  DYSENTERV SURGICAL  TREATMENT.  283 

for  a  sufficient  time  (three  or  four  days)  to  establish  ad- 
hesions about  the  proximal  end  before  cutting  away  the 
distal  portion,  and  using  the  appendiceal  stump  lumen 
through  which  to  irrigate  with  the  desired  solutions. 

The  writer  has  practised  this  latter  method  and  irri- 
gated the  colon  with  formalin  boric,  copper  phenol-sulpho- 
nate  and  quinine  solutions  with  most  gratifying  results. 
It  was  observed,  however,  that  the  irrigations  alone  did 
not  effect  a  cure.  Topical  applications  (per  sigmoido- 
scope  or  proctoscope)  were  in  all  cases  used  in  conjunc- 
tion. 

Dr.  J.  A.  Crisler,  of  Memphis,  in  1906,  advised  the  an- 
chorage of  the  appendix  in  a  small  stab  wound  below  the 
high  incision,  which  is  made  with  the  view  of  inspecting 
the  liver  and  gall  bladder. 

In  two  chronic  cases  the  writer  was  forced  to  perform 
rectal  valvotomies  on  account  of  obstruction  to  drainage, 
and  to  the  insertion  of  the  proctoscope  or  even  the  tube 
beyond  the  valves,  which  were  tightly  stretched  across  the 
lumen  of  the  rectum.  This  operation  will  rarely  be  found 
necessary. 

The  writer  here  wishes  to  acknowledge  with  thanks  val- 
uable assistance  rendered  by  Dr.  H.  P.  Conley  in  the 
preparation  of  this  chapter. 


19 


CHAPTER  XIV. 


PROLAPSE  OF  THE  RECTUM  IN  CHILDREN. 

Prolapsus  Recti,  or  prolapse  of  the  rectum,  is  the  de- 
scent, with  or  without  protrusion,  of  one  or  all  of  the  coats 
of  the  rectum,  uncomplicated  by  any  other  diseased  con- 
dition. Prolapsus  aui  is  usually  understood  to  mean  the 
descent  and  protrusion  of  either  the  mucous  membrane 
alone  or  all  of  the  coats  of  the  anus  and  lower  end  of 
the  rectum  outside  of  the  anal  aperture. 

Prolapse  may  be  either  partial  or  complete.  Partial 
prolapse  meaning  that  condition  in  which  the  mucous 
membrane  alone  protrudes;  complete  prolapse  describ- 
ing the  descent  of  all  of  the  coats  of  the  rectum.  The 
complete  variety  is  divided  into  three  varieties,  accord- 
ing to  the  degree  or  extent  of  the  prolapse. 

Prolapse  of  the  first  degree  is  the  condition  in  which 
the  prolapsed  portion  begins  at  the  anal  margin,  and  the 
mucous  membrane  covering  it  can  be  seen  to  be  continu- 
ous with  the  surrounding  skin,  there  being  no  sulcus  sur- 
rounding it.  In  complete  prolapse  of  the  second  degree, 
it  will  be  found  that  the  descent  begins  at  some  point  in 
the  rectum  above  the  sphincter  and  is  protruded  through 
the  anal  orifice,  being  telescoped  as  it  were,  through  the 
non-affected  portion  below.  In  this  variety  a  distinct 

284 


CLASSIFICATION. 


285 


sulcus  can  be  made  out  between  the  prolapse  and  the 
margin  of  the  anus. 


Fig.   111. 

Prolapse  of  the  Rectum — Third  Degree. 
(Made  from  a  photograph  of  one  of  the  author's  cases.) 
This  shows  the  prolapsing  rectum  descending  to  the  anus  but  not 
protruding. 

Prolapse  of  the  third  degree  may  begin  either  in  the 
upper  portion  of  the  rectum  or  even  in  the  sigmoid  flex- 
ure. In  this  variety  the  rectum,  and  even  the  lower  por- 
tion of  the  sigmoid,  may  descend  into  the  lower  rectal  cav- 


986  ETIOLOGY. 

ity,  but  .as  a  rule  does  not  protrude  from  the  anus.    This 
variety  is  also  known  as  concealed  prolapse.     (Fig  111.) 

Inasmuch  as  the  limitations  of  this  work  does  not  in- 
clude those  conditions  whose  relief  requires  surgical  op- 
erations under  general  anesthesia  for  their  relief,  none 
of  the  conditions  mentioned  above  will  be  treated,  save 
the  condition  most  commonly  seen  by  the  general  practi- 
tioner— prolapse  of  the  anus  and  rectum  in  children.  The 
most  frequent  variety  seen  in  children  is  that  known  as 
the  partial  or  incomplete,  and  it  consists  of  an  ever  si  on 
of  the  anal  canal,  carrying  with  it  the  mucous  membrane 
covering  the  lower  end  of  the  rectum.  It  is  a  condition 
amenable  in  the  vast  majority  of  cases  to  non-surgical 
measures,  when  seen  early  and  treated  with  patience  and 
persistence. 

Etiology.  It  is  brought  about  most  frequently 
by  severe  prolonged  or  undue  straining  efforts  on  the 
part  of  the  child.  Such  diseased  conditions  as  the  pres- 
ence of  a  rectal  polypus,  hemorrhoids,  foreign  body  in 
the  rectum,  hard  constipated  stools,  pin  worms,  stone  in 
the  bladder,  phimosis,  diarrhoea,  excessive  coughing  or 
sneezing,  accompanied  by  weakness  of  the  sphincter  mus- 
cle are  responsible  at  times,  but  most  common  of  all  is  the 
prolonged  straining  efforts  at  defecation. 

The  practice  so  commonly  in  vogue  among  moth- 
ers in  their  efforts  to  train  their  children  to  regular 
habits  of  defecation  has  been  responsible  in  the  majority 
of  cases  for  the  production  of  prolapsus  recti.  The  little 
patient  is  placed  upon  the  toilet  vessel  or  chair,  and  is 
soon  made  to  realize  what  is  expected  of  him.  Sitting 
in  the  semi-squatting  position  which  is  most  conducive 
to  the  emptying  of  the  rectum,  even  of  its  own  mucous 


SYMPTOMS DIAGNOSIS.  287 

membrane,  for  half  an  hour;  or  even  all  the  morning  (as 
has  happened  in  some  cases  which  have  come  under  the 
author's  notice),  the  little  one  using  all  his  efforts  in 
order  to  accomplish  his  daily  duty,  gradually  brings 
about  a  separation  of  the  mucous  membrane  of  the  rec- 
tum, with  accompanying  protrusion  from  the  anus. 

In  other  cases,  through  extraordinary  efforts  of  the  ab- 
dominal muscles,  the  mesentery  of  the  sigmoid  becomes 
elongated  and  an  intussusception  of  the  upper  rectum  and 
lower  sigmoid  takes  place.  Protrusion  of  the  prolapsed 
bowel  is  very  rare  in  this  instance,  and  a  condition  known 
as  concealed  prolapse  is  produced  and  often  goes  undiag- 
nosed  for  a  considerable  period  of  time.  From  an  ana- 
tomical point  of  view,  the  straightness  of  the  sacrum  in 
children  offers  less  support  to  the  rectum  than  in  adults, 
and  in  children  who  have  been  suffering  from  wasting 
diseases,  the  parts  become  so  relaxed  that  practically 
all  support  is  taken  away  from  the  rectum. 

Symptoms.  "When  the  rectum  prolapses  in  children, 
it  appears  rather  unexpectedly.  After  a  more  or  less 
long  period  of  time,  in  which  the  "training"  of  the  child 
has  been  going  on,  the  mother  is  surprised,  some  fine 
day,  by  the  appearance  of  a  ring  of  red  or  purple  hued 
membrane  surrounding  the  anus,  the  size  depending  up- 
on the  amount  of  rectum  prolapsed.  The  longer  the  pro- 
lapse remains  outside  the  rectum,  the  more  purple  hued 
it  becomes  from  the  interference  with  the  return  circu- 
lation on  account  of  the  contraction  of  the  sphincter. 

Diagnosis.  The  diagnosis  is  very  simple ;  in  fact,  self- 
evident.  The  appearance  of  a  ring  of  soft,  velvety  mucous 
membrane  protruding  from  the  anus,  is  indicative  only 


988  DIAGNOSIS TREATMENT. 

of  one  condition,  that  of  prolapse.  A  polypus  would 
be  differentiated  by  its  rounded  form,  harder  consistency 
and  the  presence  of  a  pedicle  behind  the  protrusion  ex- 
tending into  the  anus.  Hemorrhoids,  which  are  rare  in 
children,  would  be  gradual  in  onset ;  would  be  of  firmer 
consistency,  forming  separate  masses,  and  would  not  ex- 
hibit the  peculiar  red  or  purplish  appearance  of  prolaps- 
ed mucous  membrane.  On  each  succeeding  occasion, 
when  the  bowel  is  protruded,  more  of  the  mucous  mem- 
brane comes  down,  and  in  aggravated  cases  the  entire 
rectum  may  be  protruded. 

Treatment.  When  the  protrusion  first  makes  its  ap- 
pearance it  may  be  reduced  in  the  following  manner :  The 
child  is  placed  on  its  mother's  lap  with  the  buttocks 
raised  considerably  higher  than  the  head.  A  compress 
soaked  in  ice  water  placed  against  the  prolapse  will  often 
be  all  that  is  necessary.  Gentle  pressure  will  in  a  few 
minutes,  in  most  cases,  cause  a  return  of  the  prolapsed 
portion.  Oftentimes  simple  digital  pressure  of  one  side 
of  the  prolapse  while  the  buttocks  are  separated  with 
one  hand,  and  steady  pressure  made  with  the  fingers  of 
the  other,  will  suffice.  The  other  half  is  then  treated  in 
like  manner. 

Where  the  prolapse  has  remained  outside  long  enough 
to  become  swollen,  oedematous  or  congested,  and  the 
sphincter  has  contracted  upon  it;  it  will  often  be  very 
difficult  to  return  the  prolapse  unless  the  sphincter  has 
been  relaxed  by  the  injection  of  a  local  anesthetic.  In 
order  to  relieve  the  congestion  and  shrink  the  blood  ves- 
sels, the  employment  of  compresses,  soaked  with  one  to 
one  thousand  solution  of  adrenalin  chloride  and  applied 


TREATMENT NON-OPERATIVE.  289 

with  firm  pressure  to  the  protrusion  has  in  the  author's 
hands,  been  found  extremely  satisfactory.  The  blood  ves- 
sels become  constringed  and  the  mass  much  reduced  in 
size,  and  reduction  is  comparatively  easy. 

"Whenever  pressure  is  used  in  this  region,  it  should 
be  firm  but  gentle,  as  it  would  be  very  easy  to  do  ser- 
ious damage  if  the  manipulation  were  rough  or  violent. 
Wrapping  dry  absorbent  cotton  around  the  index  finger 
and  pressing  firmly  against  the  prolapse  and  in  the  di- 
rection of  the  rectal  canal,  will  often  return  a  prolapse 
with  ease.  The  finger  is  withdrawn  in  a  twisting  manner 
so  as  to  allow  the  cotton  to  remain  in  the  rectum,  from 
whence  it  is  passed  with  the  next  stool. 

If  the  child's  habits  are  corrected,  the  bowel,  in  many 
cases,  will  not  protrude  again.  In  cases,  however,  where 
the  protrusion  recurs,  a  definite  line  of  treatment  must 
be  undertaken  in  order  to  relieve  the  tendency  to  chroni- 
city  of  the  condition.  Any  exciting  cause,  such  as  stone 
in  the  bladder,  phimosis,  pin  worms,  polypus,  foreign 
body  in  the  rectum,  etc.,  must  be  relieved  by  proper  sur- 
gical measures.  If  the  case  is  due  to  constipation,  the 
child's  dietary  should  be  looked  into  and  corrected. 

Where  the  case  is  one,  however,  where  the  prolapse 
has  been  brought  upon  by  the  prolonged  sitting  at  stool, 
with  its  coincident  severe  straining  efforts,  this  method 
of  training  must  be  dispensed  with.  The  child  must  be 
made  to  move  its  bowels  in  the  recumbent  position,  either 
lying  on  its  back  or  side,  preferably  the  latter.  It  must 
not  be  allowed  to  have  movements  in  the  sitting  posture 
while  under  treatment.  The  administration  of  white  pe- 
troleum oil  or  liquid  albolene,  suitably  flavored,  in  doses 


290  CONCEALED  PROLAPSE. 

varying  from  ten  minims  four  times  a  day  in  an  infant, 
to  a  teaspoonful  for  the  child  of  five  or  six  years  of  age, 
should  be  resorted  to  in  order  to  keep  the  stools  soft 
and  the  intestinal  canal  well  lubricated.  It  is  important 
after  the  bowel  movements  to  strap  the  buttocks  together 
with  strips  of  adhesive  plaster ;  and  in  some  cases  it  may 
be  advisable  to  keep  a  pad  made  of  absorbent  cotton, 
wrapped  with  gauze,  firmly  against  the  anus. 

This  treatment  will  be  very  successful  if  persisted  in 
long  enough.  The  author  would  advise  two  months  as 
the  average  length  of  treatment  in  the  average  case.  Any 
tendency  towards  diarrhoea  should  be  immediately  look- 
ed after,  and  the  dietary  cause  for  it  discovered  and  cor- 
rected, for  the  violent  peristalsis  which  accompanies 
diarrhoea  is  often  productive  of  as  bad,  if  not  worse, 
results,  than  the  straining  efforts  of  constipation. 

Concealed  Prolapse. — In  some  cases  of  constipation, 
so-called,  in  infants,  all  efforts  for  successful  treatment 
will  fail ;  and  the  author  would  advise  in  these  cases  the 
examination  of  the  infant's  rectum  by  means  of  a  small- 
sized  proctoscope  or  a  large  female  cystoscope.  Occasion- 
ally, this  method  of  examination  will  be  rewarded  by  the 
discovery  of  a  prolapse  of  the  third  degree  (Fig.  Ill), 
which  extends  down  to  the  rectum  but  does  not  protrude. 
In  these  cases  the  infant  will  be  very  fussy  and  will  strain 
until  red  in  the  face,  but  all  that  rewards  his  efforts  will 
be  a  small  quantity  of  mucus  stained  with  fecal  mat- 
ter; and  the  only  way  in  which  the  child's  bowels  can 
be  emptied  is  by  means  of  enemas.  The  same  treatment 
as  outlined  for  the  incomplete  prolapse  is  indicated  in  this 
condition. 


EDUCATION    OF   MOTHERS.  291 

The  principal  point  in  the  prevention  and  the  treat- 
ment of  prolapse  of  the  rectum  in  children,  is  the  edu- 
cation of  the  mothers  along  the  line  of  the  so-called  train- 
ing of  infants.  While  it  is  not  the  province  of  this  work 
to  go  into  the  subject  of  infant  feeding,  nevertheless,  the 
author  feels  that  if  more  attention  is  paid  to  the  pres- 
ence of  sufficient  hydrocarbon  elements  in  the  child's 
dietary,  and  the  child  is  made  to  drink  sufficient  water, 
much  good  would  result.  Instead  of  forcing  the  little 
one  to  sit  upon  the  toilet  seat  from  half  an  hour  to  an 
hour  and  a  half,  or  even  longer,  the  child's  bowels  would 
move  with  regularity  and  with  ease  and  prolapse  would 
become  a  very  rare  condition.  The  squatting  posture 
as  assumed  by  the  aborigines  is  the  best  for  the  children 
to  assume.  If  after  ten  or  fifteen  minutes  at  the  stool 
the  child  does  not  have  a  movement,  it  is  better  far  to 
insert  a  soap  suppository  or  administer  a  small  enema 
to  tide  it  over  occasionally,  than  to  indulge  in  the  perni- 
cious custom,  seemingly  so  prevalent. 

When  in  spite  of  strapping  and  the  proper  control  of 
the  bowel  movements,  the  prolapse  still  persists  in  re- 
appearing, it  becomes  necessary  to  do  something  more 
radical.  The  method  which  has  been  most  satisfactory 
in  the  hands  of  the  author  and  which  is  particularly  adap- 
table to  prolapse  of  the  rectum  in  children,  is  what  is 
known  as  linear  cauterization.  This  may  be  accomplished 
in  two  ways — either  by  application  of  strong  nitric  acid 
or  the  use  of  the  actual  cautery.  Neither  method  is  ap- 
plicable with  entire  satisfaction  unless  a  general  anesthe- 
tic is  employed.  Nitrous  oxide,  however,  can  be  used  in 
these  cases  with  perfect  safety  and  makes  a  very  depend- 
able and  satisfactory  anesthetic. 


292 


CAUTEB1ZATION    BY   NITRIC  ACID. 


Cauterization  by  Nitric  Acid.— The  child  is  placed  in 
the  lithotomy  position  with  the  prolapse  unreduced,  and 
is  placed  under  the  influence  of  the  nitrous  oxide  gas. 
The  protruding  mucous  membrane  is  wiped  dry  and  a 


Fig.   112. 

Prolapsus  of  the  Rectum,  First  Degree,  Showing  Radiating  Lines  of 

Cauterization. 

wooden  applicator,  one  end  of  which  has  been  wrapped 
with  a  very  small  quantity  of  absorbent  cotton  moistened 
with  fuming  nitric  acid,  is  all  that  is  necessary.  The  acid  is 
applied  in  4  to  6  radiating  lines  (Fig.  112),  beginning  at 
the  uppermost  portion  of  the  center  of  the  prolapsed  muc- 
ous membrane  at  the  lumen  of  the  gut,  and  with  consid- 
erable pressure  a  line  is  drawn  or  painted  to,  but  not 
touching,  the  muco-cutaneous  juncture.  Four  to  six 


LINEAR  CAUTERIZATION  WITH  THE  ACTUAL  CAUTERY.      293 

equidistant  cauterizations  are  made  in  this  manner  and 
an  ointment  composed  of  a  drachm  of  bicarbonate  of 
soda  to  an  ounce  of  petrolatum  freely  applied.  A  piece 
of  rubber  drainage  tube  the  size  of  a  lead  pencil,  is  wrap- 
per with  gauze  until  it  forms  a  plug  or  packing  about 
%  of  an  inch  in  diameter  in  its  center  and  tapering  at 
its  extremities,  is  used  to  force  the  prolapse  back  into 
the  rectum,  and  is  left  there  for  three  or  four  days  if  pos- 
sible. The  little  patient's  suffering  after  the  operation 
is  not  very  acute,  but  if  there  should  be  much  pain,  it 
should  be  controlled  by  suitable  doses  of  codein  or  mor- 
phine hypodermatically;  Vs  to  a/4  grains  of  codein  will 
answer  very  nicely  in  children  from  l1/^  to  3  years  old. 

The  after  treatment  consists  in  the  same  methods  and 
procedures  as  that  advocated  above  in  regard  to  diet,  de- 
fecation in  the  recumbent  position,  the  strapping  of  the 
buttocks,  etc.  After  three  weeks  the  child  may  be  al- 
lowed to  resume  defecations  in  the  squatting  position.  In 
the  first  dressing  immediately  after  the  operation  it  is 
wise  to  exert  some  pressure  against  the  anus,  by  means 
of  a  suitable  pad  kept  in  place  by  adhesive  plaster  straps. 

Linear  Cauterization  with  the  Actual  Cautery. — The 
patient  is  prepared  as  described  in  the  preceding  para- 
graph and  when  the  prolapse  is  protruding  to  its  fullest 
extent,  a  Paquelin  cautery  armed  with  a  blunt  point,  and 
heated  to  a  white  heat  is  used  for  making  the  cauteriza- 
tion in  the  same  manner  as  the  nitric  acid  is  used.  (Fig. 
112.)  One  should  be  careful  to  carry  the  cauterization 
through  the  mucous  membrane  and  into  the  muscular 
layer,  but  should  be  extremely  cautious  about  burning 
through  the  muscular  tissue.  The  amount  of  destruction 


294  TREATMENT CAUTERIZATION. 

of  tissue  is  more  apparent  than  real;  one  must  remember 
the  object  of  the  cauterization  is  to  accomplish  the  con- 
traction of  redundant  tissues,  and  it  is  the  contracting 
scar  which  invariably  follows  the  use  of  the  cautery,  upon 
which  we  depend  to  accomplish  the  results.  In  this  con- 
dition we  take  advantage  of  the  great  contraindication  to 
the  use  of  the  actual  cautery  in  the  surgery  of  the  rectum, 
for  we  well  know  that  the  scar  produced  by  a  burn  >on  mu- 
cous membrane,  invariably  contracts  to  such  an  extent  as 
to  lessen  the  calibre  of  the  rectum.  The  after  treatment 
dressing,  packing,  is  the  same  as  described  where  nitric 
acid  is  used  as  a  cauterizing  agent. 

Where  these  methods  fail,  there  is  nothing  left  to  do 
but  one  of  the  cutting  operations  under  surgical  anes- 
thesia and  preferable  in  hospital  surroundings.  When 
such  is  the  case,  the  operation  had  best  be  done  by  one 
who  is  specially  trained  in  this  line  of  work,  and  not  by 
the  general  practitioner;  as  the  operative  and  after-care 
often  taxes  the  patience,  skill  and  ingenuity  of  even  the 
trained  specialist  to  accomplish  the  desired  results. 


CHAPTER  XV. 

THE  TECHNIQUE  OF  THE  USE  OF  LOCAL  ANES- 
THESIA IN  THE  TREATMENT  OF  ANO- 
RECTAL  DISEASES. 

If  any  excuse  or  apology  were  necessary  for  the  pre- 
sentation of  this  work  to  the  profession  at  this  time, 
the  subject  matter  contained  in  this  chapter  will  be  ample 
justification.  The  dangers,  inconvenience,  and  necessary 
confinement  to  bed,  and  detention  from  business,  which 
must  attend  the  use  of  general  anesthesia  in  many  so- 
called  minor  operations,  has  created  a  demand  and  con- 
stantly enlarging  field  for  the  use  in  many  departments 
of  surgery,  of  local  anesthetics.  In  the  surgical  treat- 
ment of  diseases  of  the  rectum  and  anus  this  is  especial- 
ly true ;  and  while  there  are  many  diseased  conditions  of 
this  region  requiring  surgical  interference,  the  extent 
of  which  makes  their  operative  treatment  impossible  with- 
out general  anesthesia;  there  are,  nevertheless,  many  of 
the  more  common  diseases  of  this  part  of  the  body  which 
are  entirely  amenable  to  surgical  treatment  under  region- 
al anesthesia. 

The  development  of  the  use  of  local  anesthesia  in  the 
treatment  of  anal  and  rectal  diseases  has  progressed  to 
such  a  stage,  that  it  is  safe  to  say,  that  fully  75%  of 

295 


296  LOCAL,    ANESTHESIA AGENTS    USED. 

all  cases  of  rectal  and  anal  disease  are  amenable  to  treat- 
ment without  the  use  of  general  anesthetics. 

Various  anesthetic  agents  have  been  employed  for  the 
production  of  local  anesthesia  in  this  region,  among  which 
may  be  named  the  ethyl  chloride  spray,  and  the  injection 
of  solutions  containing  cocain  hydrochloride,  beta  eu- 
cain  hydrochlorate  and  lactate,  alypin,  stovain,  novocain. 
chloretone,  as  well  as  plain  sterilized  water. 

Formerly,  cocain  in  solutions  varying  in  strength  from 
4  to  10  per  cent  were  used.  Symptoms  of  an  alarming  na- 
ture frequently  developed  after  the  injection  of  but  a  few 
drops  of  even  a  4  per  cent  solution,  which  clearly  demon- 
strated the  toxic  properties  of  the  drug  and  the  dangers 
of  its  indiscriminate  use  in  strong  solutions.  Today  we 
know  that  the  extent  of  anesthesia  produced  depends, 
not  so  much  on  the  strength  of  the  solution,  as  upon  the 
pressure  anesthesia  produced  on  the  nerve  endings,  by  the 
amount  of  solution  injected,  rather  than  its  strength. 

Today,  therefore,  practitioners  who  are  still  partial  to 
cocain  are  using  solutions  for  injection,  varying  in 
strength  from  1-10  of  one  per  cent  up  to  one-half  of  one 
per  cent,  and  find  the  latter  strength  equal  to  the  severest 
test.  The  author,  after  a  trial  of  all  of  the  anesthetics 
mentioned  above,  places  his  main  reliance  on  beta  eucain 
lactate  where  he  requires  a  chemical  anesthetic ;  and  plain 
sterile  water  in  some  few  selected  cases.  The  lactate  of 
beta  eucain  is  used  in  preference  to  the  hydrochlorate 
because  of  the  fact  that  solutions  of  the  former  salt  can 
be  sterilized  by  boiling  without  detriment. 

The  strength  of  the  solution  varies  according  to  the 
part  to  be  anesthetized,  as  well  as  the  amount  of  work 


ANESTHETIC    SOLUTIONS.  297 

to  be  done.  For  injection  into  the  skin,  and  for  the  anes- 
thetization of  the  sphincterian  nerves,  one-fourth  to  one- 
half  of  one  per  cent  solution  is  strong  enough.  For  the 
distension  of  the  tissues,  for  instance,  in  operating  for 
fissure  or  internal  hemorrhoids,  a  one-tenth  of  one  per 
cent  solution  will  suffice.  Another  important  reason  for 
my  preference  for  eucain  over  cocain,  is  the  fact  that  eu- 
cain  is  less  than  one-half  as  toxic  as  cocain,  and  is  fully 
as  powerful  in  its  anesthetic  properties.  Chloretone,  in 
the  strength  of  one-half  of  one  per  cent,  may  be  used  with 
impunity  in  place  of  the  one-tenth  of  one  per  cent  solu- 
tion of  eucain  in  such  operations  as  require  considerable 
amount  of  sol'ution.  It  is  not  toxic  and  has  the  added  ad- 
vantage over  the  other  drugs  of  being  an  antiseptic  as 
well  as  an  anesthetic.  The  use  of  sterile  water  as  an 
anesthetic  in  the  treatment  of  rectal  and  anal  diseases, 
was  exploited  prominently  a  few  years  ago,  and  while  the 
author's  experience  with  it  has  proven  to  him  that  satis- 
factory anesthesia  in  certain  cases  can  be  produced  by  its 
use  alone ;  he  limits  its  use  in  his  work  at  present  to  the 
distension  of  internal  hemorrhoids  only.  The  one  objec- 
tion which  he  has  found  to  its  indiscriminate  use  is  the 
larger  degree  of  discomfort  to  the  patient  at  the  initial 


Fig.  113. 

Aseptic  All-Glass  Hypodermic  Syringe  Provided  With  Asbestos 
Packed  Plunger. 


298  INSTRUMENTS   REQUIRED. 

injection,  and  the  large  quantities  of  solution  required 
in  some  operations  in  the  sphincterian  region,  causing 
such  distortion  of  the  tissues,  as  to  not  only  impede  the 
work  of  the  operator;  but  to  displace  the  parts  so  that 
accurate  work  could  not  be  done. 

It  is  well  for  the  reader  to  realize  that  in  "a  pinch" 
sterile  water  can  be  used  in  lieu  of  any  chemical  anesthe- 
tic, and  there  are  occasions  when  he  may  be  called  upon 
to  do  work  in  an  emergency,  where  the  various  chemical 
anesthetics  may  not  be  available ;  when,  with  an  ordinary 
hypodermic  syringe  and  boiled  water  satisfactory  anes- 
thesia can  be  produced. 


Fig.  114. 

Aseptic  All-Metal  Syringe  Provided  With  Extension  for  Infiltrating 
Through  the   Proctoscope. 

The  principal  instruments  required  for  the  production 
of  local  anesthesia  is  a  hypodermic  syringe  such  as  is 
used  for  the  injection  of  antitoxin;  which  may  be  con- 
structed either  entirely  of  metal  or  glass  (Figs.  113  and 
114)  so  that  it  can  be  readily  sterilized  by  boiling.  This 
syringe  should  have  a  capacity  of  from  2  to  4  drachms. 
The  needles  used  should  be  the  finest  that  can  be  procured 
and  the  points  should  always  be  kept  sharp.  A  quick  punc- 
ture with  a  sharp  pointed  fine  needle  is  almost  painless, 
while  the  use  of  a  larger  calibred  needle  with  a  short  bev- 
eled point,  will  cause  considerable  and  unnecessary  dis- 
comfort to  the  patient.  The  piston  syringe  package,  con- 


PREPARATION   OF  PATIEXT.  299 

structed  of  glass  and  rubber,  which  many  of  the  manu- 
facturers of  antitoxin  supply,  when  sterilized  by  boiling, 
makes  a  fairly  good  substitute  for  the  regular  aseptic  hy- 
podermic syringe,  and  in  the  absence  of  the  proper  ap- 
paratus it  may  be  used.  The  objection  to  it  is  the  fact 
that  the  needles  supplied  with  it  are  usually  of  large  cal- 
ibre and  not  as  sharp  as  they  should  be  for  this  work. 
The  only  other  piece  of  apparatus  required  (and  even 
that  is  not  an  absolute  necessity)  is  a  portable  mechani- 
cal vibrator,  armed  with  a  cone-shaped  rectal  vibratode, 
(Fig.  117),  for  use  in  the  dilatation  of  the  sphincter 
muscle. 

The  solution  used  should  be  accurately  prepared  as 
to  the  percentage  of  chemical  anesthetic  used.  Where 
beta  eucain  lactate  is  employed,  the  solution  is  made  up 
and  placed  in  an  ordinary  test  tube.  It  is  sterilized  by 
boiling  over  the  flame  of  a  Bunsen  burner  or  spirit  lamp, 
and  then  stoppered  with  absorbent  cotton  and  allowed  to 
cool.  The  solution  is  prepared  freshly  for  each  opera- 
tion. 

The  patient  is  prepared  for  the  operation  as  follows: 
Twenty-four  hours  before  the  operation,  he  is  given  a 
brisk  cathartic  and  is  instructed  to  partake  of  nothing 
but  liquid  food  thereafter.  On  the  morning  of  the  opera- 
tion the  bowels  are  washed  out  by  means  of  a  large  soap 
enema,  and  he  is  directed  to  report  at  the  office  about  one- 
half  hour  before  the  time  for  operation.  He  is  then  given 
a  quarter  of  a  grain  of  morphine  by  mouth. 

AVhen  ready  to  operate,  the  patient  is  placed  upon  the 
table  in  the  left  lateral  position,  the  left  leg  being  ex- 
tended and  the  right  well  flexed.  The  clothing  is  placed 
well  out  of  the  way,  and  the  patient  covered  with  clean 

20 


300  TECHNIQUE  FOB  ANESTHETIZATION. 

sheets.  The  anus  and  perineum  is  shaved  and  scrubbed 
with  liquid  antiseptic  soap,  then  washed  with  a  one  to 
1000  solution  of  iodide  of  mercury,  which  is  washed  off 


Fig.  115. 

Exact  Point  of  Puncture  for  the  Injection  of  Local  Anesthetics  for 

Dilating  the  External  Sphincter. 

With  the  patient  in  the  lateral  position,  a  point  from  %  to  ^2  inch 
posterior  to  the  posterior  commissure  of  the  anus  is  chosen  for  the 
first  injection. 

with  sterile  water,  and  a  compress  of  alcohol  applied.  A 
point  one-half  inch  below  and  posterior  to  the  posterior 
commissure  of  the  anus  is  selected.  (Fig.  115.)  A  spray 
of  ethyl  chloride  or  the  application  of  a  drop  of  pure  car- 
bolic acid  is  used  to  lessen  the  pain  which  accompanies 
the  introduction  of  the  needle.  Wherever  it  is  possible, 
the  index  finger  of  one  hand,  protected  by  a  finger  cot 
and  well  lubricated,  is  inserted  in  the  anus;  and  the 
sphincter  is  pulled  downward  and  backward.  The  syringe 


TECHNIQUE  FOR  ANESTHETIZATION. 


301 


containing  about  one  drachm  of  one-half  of  one  per  cent 
solution  of  eucain  lactate,  with  a  fine  sharp-pointed  needle 
about  two  inches  in  length  attached,  is  held  in  the  other 
hand.  The  needle  is  inserted  quickly,  just  underneath  the 


Fig.  116. 

Showing  the  Amount  of  Distension  of  the  Tissues  Necessary  in 
Anesthetizing  the  Sphincters. 

skin,  and  4  to  5  drops  of  the  solution  slowly  injected.  One 
should  be  extremely  careful  about  injecting  the  solution 
too  quickly,  as  this  part  of  the  procedure  is  the  most 
painful  and  often  needlessly  causes  suffering,  particu- 
larly to  the  timid  and  neurotic  patient.  The  point  of  the 
needle  is  then  passed  inward  and  laterally,  going  down 
towards  and  into  the  external  sphincter  muscle  which 


302 


TECHNIQUE   FOR  ANESTHETIZATION. 


guided  by  the  finger  in  the  rectum  is  brought  down  to- 
wards the  needle.  The  point  of  the  needle  should  be 
kept  about  one-half  inch  from  the  anal  aperture  and  the 
injection  is  carried  up  along  the  posterior  lateral  quad- 
rant of  the  anus  for  about  three-fourths  to  an  inch.  The 
needle  is  then  retracted  to  the  point  of  puncture  but 
not  withdrawn.  It  is  then  pushed  up  on  the  other  side 
in  the  same  manner,  injecting  the  opposite  side ;  so  that 
when  the  injection  is  completed  the  wheal  of  infiltration 
is  U-shaped,  the  apex  being  at  the  point  of  puncture.  (Fig. 
116.) 


Fig.  117. 

Posture  and  Method  cf  Producing  Dilatation  of  the  Sphincter  Ani  by 

the  Use  of  a  Pcrtsble  Vibrator  Armed  with  a  Cone- 

Shaped   Vibratode. 

This  technique  allows  of  the  anesthetization  of  the 
sphincterian  nerves  of  both  sides  from  but  a  single  punc- 
ture. Care  should  be  taken  lest  the  rectal  wall  be  punc- 


DILATATION  OF  SPHINCTER. 


303 


tured,  but  with  the  index  finger  of  one  hand  in  the  aims 
during  this  procedure,  such  an  accident  should  not  oc- 
cur. Three  or  four  minutes  are  allowed  to  elapse  to  al- 
low complete  anesthesia  to  take  effect ;  then  the  vibrator, 
to  which  has  been  attached  the  cone-shaped  vibratode, 
well  lubricated,  is  pressed  against  the  anus.  (Fig.  117.) 
With  very  little  pressure,  but  with  the  apex  of  the  vibra- 
tode kept  in  the  direction  of  the  axis  of  the  ano-rectal 
canal ;  from  two  to  three  minutes  vibration  will  dilate  the 
sphincter  painlessly  to  a  sufficient  calibre  to  allow  what- 


Fig.  118. 
The  Amount  of  Dilatation  of  the  Sphincter  Under  Local  Anesthesia. 

This  drawing  made  from  a  photograph  of  one  of  the  author's  cases  of 
internal  hemorrhoids,  well  illustrates  the  amount  of  dilatation  of  the 
sphincter,  which  may  be  produced  under  locr.l  anesthesia.  While  com- 
plete divulsion  is  neither  possible  nor  necessary,  sufficient  distension  is 
here  secured  to  successfully  remove  the  internal  hemorrhoids  seen  in 
the  drawing. 


304         ANESTHETIZATION    FOR   EXTERNAL    HEMORRHOIDS. 

ever  operation  is  to  be  done,  to  be  accomplished  without 
difficulty.  (Fig.  118.)  Complete  divulsion  of  the  sphinc- 
ter can  very  rarely  be  accomplished  by  this  means,  but  the 
dilatation  will  be  amply  sufficient  for  our  purposes. 

The  vibrator  is  a  very  convenient  apparatus  to  have 
at  hand,  as  the  dilatation  can  be  more  quickly  and  evenly 
accomplished  by  its  use.  In  its  absence,  however,  one 
may  use  the  index  fingers  of  both  hands  protected  by 
finger  cots  or  rubber  gloves,  and  by  a  gentle  to  and  fro 
massaging  movement,  gradually  accomplish  dilatation  in 
a  very  satisfactory  manner.  One  should  never  use  any 
of  the  dilating  rectal  speculums  in  the  dilatation  of  the 
sphincter.  The  fingers  are  far  better  dilators,  and  can 
do  no  damage  with  intelligence  and  care  behind  them  to 
guide  them. 

The  technique  for  operating  for  the  various  conditions 
amenable  to  operative  treatment  under  local  anesthesia 
will  be  dwelt  upon  more  in  detail  in  their  respective  chap- 
ters, while  the  differences  in  technique  of  anesthetization 
will  be  taken  up  below.  Suffice  it  to  say,  however,  at 
this  point,  that  no  operation  upon  the  anus  or  rectum 
should  be  undertaken  under  local  anesthesia,  ivhich  will 
require  extensive  dissection  or  over  twenty  minutes  of 
time  for  its  completion. 

External  Hemorrhoids.  If  the  hemorrhoid  is  entirely 
external  and  is  not  complicated  by  any  other  anal  con- 
dition, it  will  not  be  necessary  to  anesthetize  the  sphinc- 
ter. After  the  usual  preparation  for  operation,  the  most 
dependent  hemorrhoid  is  injected  from  its  base  with 
one-half  of  one  per  cent  solution  of  eucain  lactate,  about 
20  to  30  minims  being  used  directly  under  the  skin.  If 


ANESTHETIZATION  FOB  THROMBOTIC  HEMORRHOIDS.      305 

further  distension  is  required  in  order  to  produce  com- 
plete anesthesia,  sterile  water  may  be  used  for  the  deep- 
er injection.  After  two  minutes  the  skin  may  be  incised 
painlessly  and  the  operation  proceeded  with.  Where 
more  than  one  hemorrhoid  is  to  be  operated,  they  may 
all  be  anesthetized  at  once,  if  the  operator  is  rapid  in  his 
work ;  otherwise  they  had  best  be  anesthetized  separately 
when  ready  to  operate  on  each. 

Acute  Thrombotic  Hemmorhoids.  The  acute  throm- 
botic  hemorrhoid  is  usually  single,  occurring  just  at  the 
anal  margin.  After  being  prepared  for  operation,  eight 
or  ten  drops  of  the  one-half  per  cent  eucain  solution  is 
injected  just  beneath  its  outer  covering,  whether  skin  or 
mucous  membrane ;  care  being  taken  not  to  inject  deeply 
and  into  the  clot.  Sufficient  solution  should  be  used  to 
distend  the  tissues  over  the  clot  and  blanch  them  to  white- 
ness. It  may  then  be  incised  painlessly  and  the  clot 
turned  out.  It  is  well  after  the  turning  out  of  the  clot 
to  inject  the  tissues  beneath  it,  and  examine  carefully  as 
sometimes  a  second  clot  may  be  found  beneath  the  first, 
which  must  be  removed  in  like  manner. 

Perianal  Abscess.  In  those  cases  of  perianal  abscess 
not  extensive  enough  to  require  general  anesthesia  for 
their  operative  treatment,  the  use  of  a  local  anesthetic 
is  well  adapted.  The  technique  of  injection  is  the  same 
as  that  outlined  above  for  thrombotic  hemorrhoids.  The 
reader  is  cautioned  to  make  his  injection  very  carefully, 
so  as  not  to  perforate  the  abscess  cavity  with  the  needle. 
The  solution  must  be  injected  into  the  skin  itself  and 
directly  under  it.  After  waiting  two  or  three  minutes 
for  anesthesia  to  take  place,  the  abscess  may  be  opened 
with  absolutely  no  pain. 


306  ANESTHETIZATION  FOR  FISSURE  AND  FISTULA. 

Fissure  in  Ano.  In  all  cases  of  fissure,  the  sphincter 
should  be  anesthetized  and  dilated.  In  many  cases  where 
the  fissure  is  situated  low  down,  the  anesthetic  solution 
injected  for  the  anesthetization  of  the  sphincter,  will  also 
be  sufficient  for  the  incision  or  excision  of  the  fissure  as 
well.  Where  the  fissure  is  more  extensive  and  with  an  in- 
durated base,  or  is  located  at  some  other  portion  of  the 
anus  than  its  usual  site,  the  posterior  commissure ;  it  must 
be  injected  separately.  One-tenth  of  one  per  cent  solu- 
tion of  eucain  or  one-half  per  cent  solution  of  chlore- 
tone  may  be  used.  The  syringe  should  be  filled.  The 
needle  should  be  inserted  about  one-quarter  of  an  inch 
below  the  outermost  extremity  of  the  fissure,  or  beyond 
the  sentinel  pile  when  one  is  also  present. 

The  skin  and  mucous  membrane  surrounding  the  fis- 
sure or  induration,  as  the  case  may  be,  should  be  infil- 
trated to  such  an  extent,  that  the  fissure  is  raised  on  a 
white  waxy  looking  mound,  and  lies,  as  it  were,  on  a  water 
bed.  It  may  require  as  much  as  three  drachms  of  solu- 
tion, but  distension  of  the  tissues  is  essential  before 
thorough  work  can  be  done.  Anesthesia  should  be  car- 
ried below  the  base  of  the  fissure  for  at  least  a  quarter 
of  an  inch. 

Fistula.  The  only  variety  of  fistula  in  which  it  is  ad- 
visable to  use  local  anesthesia  as  a  routine  measure  is 
that  of  a  simple,  shallow,  complete,  fistula  whose  course  is 
direct  and  not  branching'.  A  blind  external  or  internal 
fistula  whose  opening  is  not  over  one  inch  from 
the  anus  and  whose  extent  can  be  accurately  gauged, 
may  be  opened  under  local  anesthesia.  As  a  gen- 
eral proposition,  with  the  exception  of  the  three 


ANESTHETIZATION   FOR   HYPERTBOPHIED  PAPILLAE.       307 

varieties  mentioned,  general  anesthesia  (nitrous  oxide 
wherever  possible)  should  be  used  in  operations  for  fis- 
tula in  ano.  The  sphincter  should  be  anesthetized  in  all 
cases.  The  skin  and  mucous  membrane  above  the  fistula 
should  be  infiltrated  with  the  1-10  per  cent  eucain  solution 
and  then  by  successive  injections  the  entire  fistulous 
tract  surrounding  with  the  injected  anesthetic  fluid.  The 
infiltration  should  be  carried  to  the  point  of  blanching. 
The  operation  then  may  be  proceeded  with  as  outlined 
in  the  chapter  on  fistula. 

Hypertrophied  Anal  Papillae.  In  cases  where  hy- 
pertrophy of  the  anal  papillae  is  not  accompanied  by  a 
tightly  contracted  sphincter,  it  is  possible  to  remove 
the  papilla  under  local  anesthesia  without  dilatation  of 
the  sphincter.  It  is  advisable,  however,  in  order  to 
overcome  the  tenesmus  and  painful  spasmodic  contrac- 
tions of  the  sphincter  following  any  operation  in  the  anal 
canal,  to  anesthetize  the  sphincter  as  a  general  rule  in 
removing  these  papillae.  "Where  this  is  done  the  anus  is 
held  open  by  means  of  a  retractor  and  each  papilla  is  in- 
jected from  base  to  apex  with  the  1-10  of  one  per  cent 
eucain  solution.  It  may  then  be  removed  painlessly,  and 
each  successive  one  injected  in  turn  before  removal. 

Where  the  sphincter  is  not  anesthetized,  the  use  of  a 
short  anoscope  such  as  has  been  described  by  the  author, 
with  its  internal  opening  on  the  slant,  will  be  required. 
The  papilla,  as  it  hangs  down  or  projects  into  the  open- 
ing of  the  anoscope,  is  injected  by  means  of  a  long  needle 
attached  to  the  hypodermic  syringe,  and  injected  as  de- 
scribed above.  Where  it  is  desired  to  open  the  crypts 
of  Morgagni  as  well,  the  needle  should  be  carried  up  for 


308  ANESTHETIZATION   FOR  VALVOTOMY. 

half  an  inch  or  so,  when,  after  the  removal  of  the  pa- 
pilla, the  crypt  can  be  split  open  at  will. 


Fig.  119. 
Author's  Modification  of  the  Martin  Operating  Proctoscope. 

The  obturator  has  a  conical  shaped  extremity  and  is  made  of  metal. 

Hypertrophied  Rectal  Valves.  In  operating  for  the 
section  of  hypertrophied  Houston's  valves,  the  dilatation 
of  the  sphincter  as  outlined  above,  is  often  the  only  part 
of  the  operation,  where  a  local  anesthetic  is  required. 
The  valves  themselves  are  very  poorly  supplied  with  sen- 
sory nerves,  and  as  a  result,  incision  is  painless.  In 
some  cases,  however,  there  is  some  sensitiveness  to  pain ; 
so  it  is  wise  in  all  cases  to  be  on  the  safe  side,  and  apply 
by  means  of  an  applicator  bent  at  a  right  angle,  a  four 
per  cent  solution  of  beta  eucain  to  both  upper  and  lower 
surfaces  of  the  valve.  After  waiting  two  minutes,  opera- 
tion may  be  begun. 

Removal  of  Foreign  Bodies.  Oftentimes  small  splint- 
ers of  bone,  pins  or  other  swallowed  foreign  bodies  will 
traverse  the  entire  gastro-intestinal  tract  without  doing 
any  injury,  or  becoming  lodged,  until  they  reach  the 
lower  end  of  the  rectum,  when  they  impinge  against  the 
rectal  aspect  of  the  mucous  membrane  covering  the 
sphincter  muscle.  By  their  constant  irritation,  they  cause 


ANESTHETIZATION  FOB  PEBIANAL  GROWTHS.  309 

spasm  of  the  muscle  and  intense  suffering.  On  account 
of  the  tonic  contraction  of  the  sphincter,  which  is  caused 
by  this  irritation,  any  attempt  at  the  insertion  of  a  proc- 
toscope or  even  the  finger  is  usually  futile.  The  dilata- 
tion of  the  sphincter  by  means  of  the  technique  outlined 
above,  is  nowhere  more  applicable  than  in  this  class  of 
cases,  and  not  only  such  foreign  bodies  as  have  been 
mentioned,  but  fecal  concretions  and  impactions  of  con- 
siderable size  can  be  removed  without  the  employment 
of  a  general  anesthetic  as  well. 

Removal  of  Benign  Perianal  Growths.  Small  benign 
growths  situated  at  or  near  the  anal  orifice,  such  as  der- 
moids,  sebaceous  cysts,  lipomata  or  condylomata  are 
very  satisfactorily  removed  under  local  anesthesia,  under 
the  following  technique: 

After  the  parts  are  cleansed,  sterilized  and  shaved, 
condylomata  are  removed  by  the  application  of  a  4  per 
cent  solution  of  eucain  to  the  parts,  which  is  repeated 
every  two  or  three  minutes  for  10  minutes.  Then  if  anes- 
thesia is  not  complete,  the  parts  are  sprayed  with  ethyl 
chloride  solution,  the  condylomata  quickly  snipped  off 
with  sharp  scissors  curved  on  the  flat,  and  fuming  nitric 
acid  applied  with  a  wooden  applicator,  or  a  small  tight 
swab.  Boro-chloretone  powder  is  then  applied,  and  the 
parts  covered  with  a  gauze  dressing.  In  the  case  of  a 
dermoid  or  sebaceous  cyst,  or  fatty  tumor,  the  technique 
is  the  same  for  the  removal  of  any  of  the  three  varieties. 
The  skin  covering  the  tumor  is  first  injected  with  one-half 
per  cent  solution  of  eucain  lactate,  a  wheal  or  welt 
being  formed  over  the  proposed  line  of  incision.  The 
incision  is  made  and  the  tissues  above  and  surrounding 


310          ANESTHETIZATION  FOR  POSTERIOR  PROCTOTOMY. 

the  tumor  infiltrated  with  one-tenth  of  one  per  cent  solu- 
tion of  eucain  lactate  or  sterile  water;  when  the  dissec- 
tion and  removal  of  the  growth  can  be  accomplished 
easily,  with  forceps  and  scissors.  Care  should  be  taken 
in  the  cases  of  a  cystic  tumor  not  to  puncture  the  cyst 
wall  with  the  injecting  needle,  and  in  the  excision  of  the 
growth  to  be  sure  to  remove  all  of  the  sac.  If  this  is  not 
done,  recurrence  is  liable  to  follow. 

Posterior  Internal  Proctotomy  for  annular  stricture 
situated  in  the  anal  canal,  or  not  over  one-half  an  inch 
above  the  ano-rectal  juncture. 

With  the  patient  in  the  left  lateral  position,  and  pre- 
pared for  operation,  the  region  posterior  to  the  anus, 
anal  canal,  and  stricture,  is  infiltrated  with  one-tenth  of 
one  per  cent  solution  of  eucain  lactate.  After  waiting 
two  or  three  minutes  for  anesthesia  to  take  full  effect, 
the  stricture  is  divided  in  the  posterior  median  line 
down  to  the  rectal  wall,  with  a  sharp  scalpel,  a  piece  of 
gauze  inserted,  and  the  operation  is  complete.  The  au- 
thor's technique  for  rectal  valvotomy  by  the  use  of  the 
rubber  ligature  may  be  substituted  for  the  incision,  if 
the  calibre  of  the  stricture  is  sufficiently  large  enough  to 
admit  the  ligature  carrier.  After  operation,  the  recur- 
rence of  the  stricture  is  prevented  by  the  introduction 
of  Wales'  bougies  up  to  size  No.  12,  twice  a  week  at  first, 
and  at  increasing  intervals  until  complete  healing  has 
taken  place. 

After  carefully  perusing  what  has  been  said  regarding 
the  employment  of  local  anesthesia,  and  bearing  in  mind 
the  contra-indications  and  objections  as  outlined  in  the 
following  chapter  on  Limitations  of  Local  Anesthesia; 


OTHER  INDICATIONS.  311 

other  diseased  conditions  of  not  only  the  rectum  and 
anus,  but  in  other  parts  of  the  body,  will  present  them- 
selves, in  which  the  employment  of  local  anesthesia  will 
be  found  very  advantageous;  and  the  results  obtained 
therefrom  fully  as  successful  as  where  heretofore,  the 
employment  of  general  anesthesia  has  been  thought  abso- 
lutely necessary  and  indispensable. 


CHAPTER  XVI. 

THE  LIMITATIONS  OF  OFFICE  TREATMENT 
AND  INDICATIONS  FOR  OTHER  MEASURES. 

While  the  primary  object  of  this  work  has  been  to 
bring  before  the  profession,  the  advantages  to  be  gained 
from  the  treatment  of  various  rectal  diseases  in  office 
practice,  and  to  demonstrate  the  advantages  of  the  use  of 
local  anesthesia  in  the  treatment  of  many  of  the  more 
common  conditions  met  with  in  connection  with  the  treat- 
ment of  diseases  of  the  anus  and  rectum;  it  has  been 
thought  wise  to  utter  a  warning  note,  lest  the  reader  be 
led  away  by  over-enthusiasm. 

While  the  author  believes  that  the  field  for  the  employ- 
ment of  local  anesthesia  in  rectal  surgery,  as  well  as  in 
other  branches  of  practice,  is  rapidly  widening ;  he  wishes 
to  impress  upon  the  reader  that  this  field  has  definite 
limitations  and  that  there  is,  and  always  will  be,  a  large 
class  of  cases  whose  successful  treatment  requires  more 
radical  measures,  ivhich  only  can  be  employed  by  the  aid 
of  full  surgical  general  anesthesia. 

If  the  reader  has  carefully  read  what  has  been  said 
upon  means  and  methods  of  diagnosis,  and  has  noted 
in  the  various  chapters  following,  the  class  of  cases  in 
which  the  author  advocates  the  use  of  non-surgical  meas- 

312 


LIMITATIONS  OF  OFFICE  TREATMENT.  313 

ure  and  the  employment  of  local  anesthesia ;  he  will  have 
noted  that  the  methods  of  treatment  advocated  are  con- 
fined to  a  very  definite  class  of  cases.  All  of  the  condi- 
tions treated  of,  have  been  located  either  at,  or  in  the 
immediate  vicinity  of  the  anal  canal,  or  were  those  affec- 
tions of  the  mucous  membrane  of  the  rectum  or  lower 
sigmoid,  which  are  accessible  to  treatment  through  the 
proctoscope  or  sigmoidoscope. 

The  first  thing  one  should  remember  before  commenc- 
ing the  treatment  of  any  pathological  condition  found  in 
the  region  of  the  anus,  is  that  until  a  careful  exploration 
of  the  entire  rectal  cavity  has  been  made,  and  every 
portion  of  it  examined  with  the  eye;  he  has  not  made  a 
diagnosis,  and  has  no  right  to  treat  the  patient  until  he 
has.  It  would  be  a  sad  and  unfortunate  discovery  for 
the  physician  who  has  been  treating  an  anal  ulcer,  or  pru- 
ritus, or  hemorrhoids,  to  discover  after  several  weeks, 
that  the  condition  under  treatment  was  merely  second- 
ary to  an  extensive  ulceration  higher  up  in  the  rectum,  a 
stricture,  or  malignant  disease. 

In  women,  suffering  from  pelvic  troubles  which  may 
require  laparotomy  for  their  relief,  the  removal  of  any 
minor  rectal  condition  present  under  local  anesthesia, 
had  better  be  postponed,  and  the  rectal  or  anal  condition 
treated  at  the  time  of  laparotomy. 

In  patients  suffering  from  irregularity  or  interrup- 
tion of  their  normal  bowel  movements,  it  is  wise  to  ex- 
clude by  careful  abdominal  examination  any  possibility 
of  chronic  intestinal  obstruction,  due  to  some  abdominal 
growth,  displacement,  or  adhesions;  than  to  attempt  to 
relieve  the  patient  by  means  of  rectal  dilatation  and  mas- 
sage. 


314    CONTRA-INDICATIONS  TO  THE  USE  OF  LOCAL  ANESTHESIA. 

Every  patient  presenting  himself  with  a  fissure  or  ul- 
cerative  condition  of  the  anal  canal,  should  be  carefully 
questioned  as  to  the  possible  history  of  previous  syphilitic 
infection.  The  presence  of  gonorrhoea!  discharge,  is  a 
centra-indication  to  operative  measures  until  the  disease 
is  remedied.  In  women,  a  purulent  vaginal  discharge  as 
well  as  the  menstrual  flow  is  of  course,  a  contra-indica- 
tion. 

Patients  suffering  from  anemia  are  always  bad  sub- 
jects for  operation  at  one's  office  under  local  anesthesia, 
and  a  history  of  hemophilia  should  always  be  excluded 
before  office  operations.  Patients  of  a  highly  neurotic 
temperament  and  hysterical  females  are  best  operated 
at  home  or  in  the  hospital,  and  under  general  anesthesia. 
In  other  words,  the  suitable  cases  for  office  treatment  are 
those  suffering  from  diseased  conditions,  ivhose  patho- 
logical source  is  located  either  on  the  mucous  surface  of 
the  rectum  and  lower  sigmoid,  and  is  definitely  circum- 
scribed in  area  and  not  of  a  malignant,  syphilitic  or  tu- 
bercular type;  or  to  lesions  occurring  at  or  around  the 
anal  orifice,  ivhose  outlines  can  be  definitely  marked  out 
by  the  diagnostic  means  outlined  in  the  fore  part  of  the 
book. 

One  of  the  greatest  satisfactions  to  the  practitioner 
who  as  a  routine  measure  makes  a  proper  rectal  exami- 
nation of  his  patients  whose  symptoms  would  seem  to 
indicate  it,  is  the  discovery  of  commencing  malignant 
disease  early  enough  to  allow  of  the  removal  of  the  pri- 
mary focus,  and  the  saving  of  his  patient's  life.  As  has 
been  said  before,  a  history  of  rectal  hemorrhage,  how- 
ever slight,  is  an  imperative  demand  for  complete  explo- 


RECTAL   CANCER. 


315 


ration  of  the  rectal  cavity  and  the  most  important  con- 
dition to  be  on  the  lookout  for,  which  makes  itself  mani- 
fest early  by  rectal  hemorrhage  is  cancer.  It  is  in  this 


Fig.   120. 
Cancer  of  the  Rectum,  With  Multiple  Fistulae. 

This  drawing,  made  from  a  photograph  of  a  case  referred  to  the 
author,  tells  a  pathetic  story.  The  patient,  a  woman  aged  52.  suffering 
from  various  digestive  disturbances  and  the  appearance  of  blood  with 
the  stool,  made  her  own  diagnosis  of ''bleeding  piles;"  after  six  months 
of  self-treatment  she  consulted  an  irregular  advertising  quack,  who 
confirmed  her  diagnosis  of  "hemorrhoids,"  and  proceeded  to  "absorb 
the  growth  by  electricity."  When  her  money  ran  out  she  was  sent 
home  "cured."  Her  condition  one  month  later,  when  seen  by  the  author, 
is  illustrated  above.  The  area  of  infiltration  involved  the  entire  anus, 
posterior  wall  of  the  vagina,  and  all  of  the  perineal  body  between.  Her 
perineum  was  riddled  with  abscesses  and  fistulae.  The  rectum  and  vagina 
communicated  through  a  large  recto-vaginal  fistula,  and  the  posterior 
wall  of  the  bladder  was  infiltrated.  The  case  was  hopeless  and  she 
died  shortly  afterwards. 

21 


316  SYMPTOMS  OF  RECTAL  CANCEE. 

condition,  above  all  others,  where  an  early  complete  proc- 
tologic  and  sigmoidoscopic  examination  will  achieve  bril- 
liant results,  if  the  findings  therefrom,  will  bring  about 
an  early  operation  for  the  removal  of  the  growth.  It  is 
the  same  with  malignant  diseases  in  this  part  of  the  body 
as  in  all  others ;  if  the  surgeon  can  only  get  at  them  early 
enough  to  thoroughly  eradicate,  he  can  relieve  them  with 
a  pretty  definite  hope  of  permanent  cure. 

Inasmuch  as  rectal  cancer  most  frequently  occurs  in 
the  lower  part  of  the  organ,  the  early  operation  and  com- 
plete removal  is  productive  of  much  good.  Some  of  the 
early  symptoms  of  commencing  cancer  of  the  rectum  or 
sigmoid  are  flatulence  ivith  colicky  pains;  diarrhoea  al- 
ternating with  constipation;  tenesmus;  increased  mucous 
discharge,  ivhich  is  usually  offensive  in  odor,  and  hemor- 
rhage. This  hemorrhage  is  very  slight  at  first,  often 
showing  a  few  blood  streaks  with  the  mucous,  or  small 
passages  of  blood  either  with  the  stool  or  occasionally 
between  bowel  movements.  The  nearer  to  the  anus  the 
cancer  is  located,  the  earlier  in  the  disease  the  hemor- 
rhage, on  account  of  the  traumatism  to  the  groivth  caused 
by  the  passage  of  the  feces.  Cachexia,  loss  of  weight  and 
impairment  of  general  health  is  not  an  early  sign  of 
rectal  cancer.  The  indican  reaction  is  usually  present 
in  urine  in  cancer,  while  it  is  absent  in  ordinary  diar- 
rhoea. 

Diarrhoea  which  persists  for  some  time,  which  is  ac- 
companied by  the  presence  of  blood,  however  slight, 
should  be  regarded  as  suspicious  and  the  patient  care- 
fully watched.  When  one  considers  that  50  per  cent  of 
all  cancer  occurs  in  the  gastro-intestinal  tract,  and  that 


RECTAL   CANCER.  317 

16  per  cent  of  all  cancers  of  the  digestive  tract  occur 
primarily  either  in  the  rectum  or  sigmoid  flexure;  one 
commences  to  realize  the  importance  of  examining  every 


Fig.  121. 
Proctoscopic  View  of  Carcinoma  Situated  Just  Below  the  Juncture 

of  Rectum  and  Sigmoid. 
(Drawn  through  the  proctoscope.     Author's  case.)  ! 

case  which  presents  a  history  of  rectal  hemorrhage,  how- 
ever slight,  no  matter  the  age  or  general  appearance  of 
the  patient. 

Well  authenticated  cases  of  cancer  of  the  rectum  have 
been  found  in  cases  as  young  as  fifteen  years  of  age.  To 
show  how  much  more  frequently  cancer  is  prone  to  locate 
in  this  part  of  the  body  than  is  generally  supposed,  it  may 
be  stated  that  Boas  found  in  500  cases  of  cancer  of  the  di- 
gestive tract,  83  cases  of  cancer  of  the  rectum.  In  the  per- 
sonal practice  of  the  author,  very  frequently  patients  are 
brought  in  by  practitioners,  many  of  whom  really  try 
to  do  conscientious  work,  with  unsuspected  cancer  of  the 


318  RECTAL   CANCER. 

rectum.  Many  of  these  patients  are  in  the  forties,  pres- 
ent robust  appearance  and  come  with  a  history  of  some 
bleeding  from  the  rectum  from  which  they  make  their 


Fig.  122. 
The  Carcinoma  Shown  in  the  Preceding  Illustration. 

Drawn  from  the  specimen  removed  by  operation. 

own  diagnosis  of  "bleeding  piles."  They  also  complain 
of  some  disturbance  of  bowel  movements,  either  constipa- 
tion or  diarrhoea,  and  disturbed  gastric  and  intestinal 
digestion  and  occasionally  a  not  very  well  defined  aching 
in  the  sacral  region. 

In  many  of  these  cases  proctoscopic  and  sigmoido- 
scopic  examination  has  demonstrated  the  presence  of 
cancer  of  the  rectum,  so  far  advanced,  as  to  cause  almost 
complete  occlusion  of  the  lumen  of  the  bowel,  and  too 


RECTAL   CANCER. 


319 


far  advanced  to  extirpate  with  any  hope  of  cure.     It  is 
the  unfortunate  experience  of  many  proctologists  to  be 


Fig.   123. 
Cancer  of  the  Rectum. 

Photograph  of  specimen   removed  by  the   author. 

This  specimen,  which  includes  the  entire  rectum  and  lower  portion 
of  the  sigmoid,  being  eleven  inches  in  length,  was  removed  by  the  author 
by  the  perineal  method,  the  sphincters  being  preserved.  This  case  well 
illustrates  the  value  of  early  diagnosis  and  prompt  operative  interference 
in  cancer  of  the  rectum.  The  patient,  aged  50,  suffered  from  gradually 
increasing  disturbances  of  the  digestive  functions  for  about  six  months. 
The  symptoms  gradually  grew  worse  and  she  noticed  that  her  stools 
were  becoming  smaller  in  calibre  and  accompanied  by  a  small  quantity 
of  blood.  She  consulted  her  physician,  thinking  she  had  hemorrhoids. 
He  immediately  made  a  proctoscopic  examination  and  discovered  just 
below  and  extending  to  the  recto-sigmoidal  juncture,  a  crater-like  ulcer- 
ation  with  raised  edges,  projecting  into  the  lumen  of  the  bowel.  A  diag- 
nosis of  rectal  cancer  was  made  and  the  case  referred  to  the  author  for 
operation.  There  was  no  extra-rectal  involvement  and  the  complete 
extirpation  of  the  diseased  rectum  and  lower  sigmoid  was  followed  by 
a  rapid  recovery  of  the  patient. 


320 


RECTAL   CANCER. 


called  upon  to  inform  many  of  these  patients  of  their 
hopelessness,  and  it  is  with  the  hope  of  bringing  the  pro- 
fession in  general  to  realize  the  importance  of  examina- 
tion of  the  rectal  cavity  in  all  cases  presenting  the  symp- 
toms just  mentioned  above ;  that  so  much  stress  is  being 
laid  on  the  importance  of  early  examination  of  the  rec- 
tum by  the  general  practitioner. 


Fig.  124. 

Cancer  of  the  Rectum. 

Same  as  the  preceding.     Interior  view  of  the  specimen. 
A.    Point  of  amputation  from  the  anus. 
R-    Rectum. 
X.    Cancer. 
S.    Sigmoid   flexure. 
The  lettering  on  the  preceding  specimen   corresponds   to  the   above. 


ULCERATION COLOSTOMY — STRICTURE.  321 

Cases  of  ulceration  of  the  bowel  involving  more  than 
one  circumscribed  area  which  have  become  chronic,  as 
well  as  the  very  extensive  ulcerations  due  to  the  specific 
infections  like  tuberculosis  and  syphilis,  are  not  suitable 
cases  for  office  or  local  treatment.  It  has  been  found  in 
the  experience  of  most  proctologists  that  the  only  satisfac- 
tory way  by  which  such  cases  may  be  cured,  is  by  "  side- 
tracking" the  fecal  current  by  means  of  a  temporary 
colostomy.  This  removes  the  mechanical  as  well  as  the 
bacterial  irritation  from  the  ulcerated  surfaces  and  puts 
the  parts  at  rest ;  after  which  irrigations  and  other  suit- 
able therapeutic  measures  can  be  applied  from  above,  as 
well  as  below.  These  cases,  however,  require  more  or 
less  confinement  to  bed  or  to  the  house,  and  are  best 
treated  only  in  the  surroundings  which  the  modern  hos- 
pital can  best  supply. 

While  it  is  true  that  colostomy  can  be  performed  un- 
der local  anesthesia,  as  the  author  has  demonstrated  in 
several  cases;  it  is  hardly  to  be  advised  to  be  performed 
by  the  general  practitioner  or  included  in  the  same  class 
as  the  operative  measures  or  diseases  mentioned  in  the 
foregoing  chapters. 

No  case,  of  stricture  of  the  rectum  should  be  treated 
whether  by  dilatation,  incision,  or  electricity  in  office  prac- 
tice, unless  it  is  situated  within  the  first  two  inches  of 
the  ano-rectal  canal,  and  is  not  smaller  in  calibre  than 
the  circumference  of  a  No.  10  Wales  bougie.  Even  then, 
its  situation,  consistency,  structure  and  relation  to  the 
rectal  walls  and  impinging  organs,  should  be  definitely 
ascertained  by  digital  and  instrumental,  as  well  as  ocu- 
lar examination.  Great  caution  should  be  observed  in 


322  CIRCUM-AXAL  AND  PERI-RECTAL  ABSCESSES. 

using  forcible  dilatation  in  any  case  of  stricture  of  the 
rectum,  no  matter  how  elastic  the  stricture  may  seem. 
Accidents  have  been  reported  where  the  rectum  has  been 
torn  through,  and  the  peritoneal  cavity  entered  with  fa 
tal  result,  from  the  simple  dilatation  of  large  calibred 
strictures  by  means  of  the  Wales  bougie.  Cases  of  ' '  stric- 
ture" due  to  unusual  infiltration  of  one  of  Houston's 
valves,  or  strictures  of  the  umbrella  type  can  be  easily 
divided  by  means  of  the  author's  rubber  ligature  opera- 
tion, as  applied  to  hypertrophied  rectal  valves. 

Where  the  administration  of  nitrous  oxide  is  so  easy, 
and  attended  with  practically  no  danger,  its  use  is  to  be 
advocated  in  those  cases  where  operation  of  a  few  min- 
utes' (not  exceeding  twenty-five)  duration  is  all  that  is 
required,  for  which  general  anesthesia  is  absolutely 
necessary. 

While,  as  has  been  pointed  out  in  a  preceding  chapter, 
some  circum-anal  and  peri-rectal  abscesses  are  amenable 
to  treatment,  within  certain  limitations,  under  local  anes- 
thesia; abscess  formation  may  go  on  to  such  a  point, 
that  it  is  absolutely  necessary  to  do  a  more  extensive 
operation  than  is  possible  under  local  anesthesia.  Cer- 
tainly no  abscess  which  extends  above  the  levator  ani 
muscle  should  ever  be  opened  under  local  anesthesia; 
nor  any  abscess  in  the  ischio-rectal  region,  in  which  there 
is  any  doubt  as  to  the  operator's  ability  to  obtain  a  large 
and  free  drainage  opening  by  means  of  incision  without 
curetting.  Owing  to  the  ease  with  which  an  abscess  may 
extend,  and  the  rapidity  with  which  it  enlarges  in  the 
ischio-rectal  region,  it  is  a  safe  plan  not  to  attempt  to 
open  the  abscess  under  local  anesthesia,  if  it  has  become 


FISTULA   IN    ANO HEMORRHOIDS.  323 

larger  than  a  hen's  egg  in  size,  unless  a  definite  point  of 
fluctuation  and  softening  can  be  detected  at  a  point,  well 
outside  of  the  sphincters. 

No  case  -of  fistula-in-ano  which  has  more  than  one 
channel  or  whose  limits  cannot  be  definitely  made  out  by 
digital  examination,  should  be  opened  under  local  anes- 
thesia. Only  the  simple,  direct,  complete,  or  blind  exter- 
nal, blind  internal,  or  sub-mucous  fistulae,  are  amenable 
to  operation  under  local  anesthesia  and  in  cases  of  doubt, 
nitrous  oxide  or  ether  should  be  employed.  One  never 
can  tell  how  high,  or  how  extensive  a  dissection  may  be 
required  for  the  complete  removal  of  a  fistulous  tract, 
which  is  the  ideal  operation. 

In  operating  for  hemorrhoids  under  local  anesthesia, 
one  must  be  extremely  careful  in  the  selection  of  cases- 
Hemorrhoids  complicated  with  fistula,  extensive  ulcera- 
tion,  prolapse,  or  abscess,  are  best  treated  only  under 
general  anesthesia.  External  hemorrhoids  and  acute 
thrombotic  hemorrhoids  can  almost  invariably  be  re- 
moved under  local  anesthesia,  fully  as  satisfactorily  as 
by  the  use  of  a  general  anesthetic.  In  the  treatment  of 
internal  hemorrhoids  and  externo-internal  hemorrhoids, 
however,  there  is  a  limit  beyond  which  it  is  possible  to 
go,  but  not  wise. 

The  author  in  his  practice  has  laid  down  the  following 
rule:  In  all  cases  of  internal  hemorrhoids  where  not  more 
than  four  separate  hemorrhoidal  tumors  are  present, 
whether  prolapsing  or  not  (see  Fig.  85),  operation  under 
local  anesthesia  is  the  method  of  choice.  Where  more  than 
four  distinct  hemorrhoidal  tumors  are  present,  or  where 
there  is  much  rectal  prolapse  complicating,  their  removal 


324  PROLAPSE  OF  THE  RECTUM. 

under  nitrous  oxide  anesthesia  is  advised.  Where,  how- 
ever, it  is  deemed  unsafe  or  inexpedient,  or  where  the  pa- 
tient absolutely  refuses  to  take  a  general  anesthetic;  the 
more  severe  cases  can  be  operated  on  under  local  anes- 
thesia by  operating  at  several  different  sittings,  remov- 
ing two  or  three  hemorrhoids  at  a  time,  and  then  in  a 
month  or  so  removing  more;  eventually  accomplishing 
the  complete  removal  of  all  the  hemorrhoids  in  three  or 
four  months  and  by  as  many  operations.  In  some  pa- 
tients suffering  from  cardiac,  pulmonary  or  renal  disease, 
such  a  method  may  have  to  be  followed  where  the  admin- 
istration of  a  general  anesthetic  would  be  absolutely  pro- 
hibited. 

In  cases  suffering  from  interno- external  hemorrhoids. 
where  there  are  more  than  four  separate  tumors,  their 
removal  may  be  accomplished  in  two  sittings  by  remov- 
ing the  external  portions  at  one  operation;  when,  with 
these  out  of  the  way,  the  internal  ones  can  be  removed 
with  ease  at  the  next  sitting. 

In  prolapse  of  the  rectum  of  the  second  degree,  where 
the  prolapsus  only  involves  one-half  of  the  circumfer- 
ence of  the  bowel,  local  anesthesia  may  be  employed  and 
the  prolapsed  portion  ligated  off  in  sections.  As  a  gen- 
eral proposition,  however,  the  author  does  not  advise 
its  use.  Operations  for  prolapse  have  been  done  by  some 
proctologists  under  local  anesthesia,  but  the  technique  is 
rather  crude,  and  the  same  satisfactory  results  cannot  be 
obtained  in  this  hurried  method,  as  are  possible  under 
general  anesthesia.  In  prolapse  of  the  third  degree  (Fig. 
Ill),  local  anesthesia  is  obviously  contra-indicated,  as  the 
most  successful  operations  for  the  reduction  of  complete 


FECAL,  CONCRETIONS COMMUNICATING  FISTULA.         325 

prolapse  is  best  accomplished  by  means  of  an  abdominal 
operation. 

The  removal  of  concretions  from  the  rectum  or  sigmoid 
which  are  larger  than  one  inch  and  a  half  in  circumfer- 
ence, should  not  be  attempted  under  local  anesthesia,  but 
can  be  done  very  nicely  under  the  anesthesia  produced  by 
the  administration  of  nitrous  oxide.  While  almost  any 
case  of  fecal  impaction  can  be  relieved  under  local  anes- 
thesia, as  has  been  pointed  out  in  Chapter  V,  there  are 
some  cases  in  which  the  procedure  fatigues  the  patient  so 
much,  that  the  administration  of  a  general  anesthetic  may 
by  necessary,  in  order  to  successfully  complete  the  opera- 
tion. 

Operations  for  fistula  communicating  betiveen  the  rec- 
tum and  other  adjacent  organs  should  never  be  attempt- 
ed under  local  anesthesia;  neither  should  the  extensive 
use  of  the  thermo  cautery  be  attempted  unless  the  patient 
is  under  profound  anesthesia,  if  used  at  all.  Before  at- 
tempting any  operation  for  relief  of  any  pathological 
condition  discovered  in  the  anus  or  rectum,  the  absence 
of  any  other  diseased  condition  higher  up  in  the  rectum, 
should  first  be  demonstrated  by  careful  proctologic  and 
sigmoidoscopic  examination. 


CHAPTER  XVII. 

THE  FECES  AND  THEIR  CLINICAL  EXAMINA- 
TION. 

BY  GEORGE  W.  WAGNER,  M.  D.,  Detroit,  Mich. 

It  is  surprising  that  in  the  study  of  intestinal  diseases 
so  little  attention  has  been  given  to  the  careful  study 
of  the  stool.  The  study  of  the  feces  bears  the  same  re- 
lation to  the  study  of  intestinal  derangements,  as  the 
examination  of  the  urine  to  the  diagnosis  of  renal  dis- 
eases. 

I  have,  as  far  as  possible,  included  only  the  practical 
part  of  cropology,  omitting  those  procedures  that  are  of 
no  particular  benefit  to  clinical  medicine  and  those  re- 
quiring special  laboratory  training. 

Under  the  term  feces  are  comprised  all  those  sub- 
stances which,  being  formed  from  the  food  in  the  process 
of  digestion,  and  mixed  with  the  residues  of  the  secre- 
tions of  the  alimentary  canal,  are  finally  expelled  by  the 
rectum. 

Number  of  Stools. — The  number  of  stools  in  24  hours 
varies  greatly  in  different  persons,  who  are  apparently 
in  good  health.  One  may  have  two  to  three  bowel  move- 
ments in  24  hours,  while  another  may  have  but  one  in  48 
hours,  so  it  is  important  to  ascertain  the  habitual  num- 

326 


DURATION  OF  PASSAGE.  327 

ber  of  stools  in  every  individual.  There  are  rare  in- 
stances in  which  one  stool  occurs  only  in  2  to  6  weeks.  It 
is  better,  however,  to  take  the  general  condition  of  the 
patient  as  a  guide  to  the  sufficiency  of  defecation.  Some 
individuals  will  tolerate  infrequent  defecations  while 
others  would  suffer  from  copremia  under  the  same  con- 
ditions. 

Duration  of  Passage. — The  question  of  the  length 
of  time  required  for  the  passage  of  food  through  the 
gastro-intestinal  canal  is  a  matter  of  much  clinical  im- 
portance, yet  little  attention  has  been  paid  to  the  subject. 
It  is  quite  as  important  to  know  the  period  of  passage 
as  to  know  how  often  the  patient  has  a  stool.  A  patient 
may  have  one  stool  a  day,  and  yet  have  latent  constipa- 
tion, which  gives  rise  to  toxic  symptoms.  Whether  latent 
constipation  is  present  can  only  be  determined  by  esti- 
mating the  period  of  passage.  In  diarrhoea,  by  estimat- 
ing the  period  of  passage,  it  is  possible  to  come  upon  an 
approximate  idea  of  the  seat  of  the  disturbance  produc- 
ing the  diarrhoea.  If  the  period  of  passage  is  nearly 
normal,  the  trouble  lies  in  the  lower  or  middle  portion  of 
the  large  intestine,  and  peristalsis  is  probably  not  in- 
creased in  the  small  intestine.  Chronic  colitis,  with  sev- 
eral watery  movements  a  day,  may  be  accompanied  by  a 
normal  passage.  The  period  is  decidedly  shortened  if 
the  inflammation  is  in  the  ascending  colon  or  small  bowel. 
Strauss  used  a  test  diet  of  100  gms.  of  lean  meat  and 
found  the  normal  period  to  be  10  to  20  hours.  This  was 
increased  in  cases  of  constipation  as  high  as  60  hours. 
Maurel  using  a  pure  milk  diet,  gives  the  normal  period  36 
to  48  hours.  In  disease  the  shortest  period  was  4  hours, 


328  NORMAL  CHARACTERISTICS. 

and  in  such  cases  the  bilirubin  is  found  unaltered.  The 
period  of  passage  is  very  easily  marked  by  giving  a  cap- 
sule of  carmine  with  the  meal  and  watching  for  the  first 
red  stool. 

Amount. — The  amount  varies  in  different  individ- 
uals, depending  upon  the  character  of  the  diet  and  the 
condition  of  the  digestive  organs.  The  quantity  is  in- 
creased by  a  diet  rich  in  vegetables  and  starchy  foods, 
and  diminished  by  one  rich  in  animal  food. 

The  stool  consists  of  the  indigestible  portion  of  the 
diet,  the  part  of  the  diet  undigested,  bacteria  and  the 
secretion  of  the  intestines  and  their  associate  glands. 
Cetti,  who  fasted  10  days,  passed  about  22  gms.  of  stool 
on  the  average  per  day.  The  normal  amount  varies  be- 
tween 100  and  200  gms.  in  24  hours. 

Consistency  and  Form. — The  consistency  of  the  stool 
depends  chiefly  upon  the  amount  of  water  it  contains, 
though  there  may  be  soft,  thin  stools  due  to  abnormal 
amounts  of  fat  or  mucus.  Increase  of  the  fluid  in  the 
stools  may  be  due  to  deficient  absorption  or  to  exudate  or 
transudate  from  the  mucous  membrane.  Increased  peri- 
stalsis may  cause  watery  stools  through  failure  of  absorp- 
tion, while  prolonged  retention  in  the  colon  or  rectum 
may  result  in  hard,  scybalous  masses  due  to  excessive 
absorption  of  water. 

Odor. — The  odor  of  the  feces  is,  to  a  large  extent,  due 
to  the  presence  of  indol,  skatol,  sulphuretted  hydrogen 
and  methane. 

Color  of  Stools. — The  color  of  the  feces  varies  ac- 
cording to  the  nature  of  the  food  ingested.  The  normal 
color  is  a  dark  brown.  A  diet  consisting  largely  of  meat 


MACEOSCOPIC    ELEMENTS.  329 

gives  an  intensely  brown  stool,  while  a  vegetable  diet 
gives  a  more  yellowish  shade  to  the  feces.  A  stool  that 
has  been  exposed  to  the  air  is  darker  on  the  outside  than 


Fig.  125. 

Sulphide  of  Bismuth  Crystals  From  the  Stools. 
(Eye   piece  III,  objective  8  A,   Reichert.) 

— Clinical  Diagnosis :  von  Jaksch  &  Cagney. 

on  the  interior,  owing  to  the  process  of  oxidation.  The 
presence  of  undigested  fats  gives  a  yellowish  shade  to 
the  stool.  If  much  blood  is  present  the  stool  may  be 
black  or  have  a  tarry  appearance.  Huckleberries  and  red 
wine  produce  a  dark  stool;  chocolate  and  cocoa,  gray; 
iron  manganese  and  bismuth  preparations  a  dark  or  black 
stool  owing  to  the  formation  of  the  oxides  of  these  met- 
als. (Fig.  125.)  Calomel  causes  a  greenish  stool  (bili- 
verdin),  santonine,  rhubarb  and  senna  produce  a  yellow 
color. 

Macroscopic  Elements. — These  are  derived  either 
from  the  food  or  from  the  intestinal  apparatus 
itself.  It  is  possible  to  find  stones,  cherry  pits, 


330 


MICROSCOPIC  ELEMENTS. 


grape  seeds,  skins  of  various  berries  or  apples,  pears 
etc.,  pieces  of  connective  tissue,  grains  of  corn- 
in  fact  almost  any  part  of  the  food  if  insufficiently 
masticated.  The  presence  of  casein  in  the  stools  of  in- 
fants appears  as  small  whitish  lumps  and  can,  as  a  rule, 
be  easily  recognized.  Foreign  bodies  of  almost  every 
description  that  are  not  too  large  to  swallow,  may  be 
found  in  the  stools,  especially  in  the  stools  of  children  and 
of  the  hysterical  or  of  the  insane ;  one  may  find  buttons, 
coins,  pins,  false  teeth,  hair  balls,  etc. 


Fig.   126. 

Collective  View  of  the   Feces. 
(Eye  piece  III,  objective  8  A,  Reichert). 

a,  Muscle  fibres;  b,  connective  tissue;  c,  Epithelium;  d,  White  blood 
corpuscles;  e,  Spiral  cells;  f-i,  Various  vegetable  cells;  k,  Triple  phosphate 
crystals  in  a  mass  of  various  micro-organisms;  I,  Diatoms. 

— Clinical  Diagnosis :   von  Jaksch  &  Cagney. 

Microscopically,  may  be  seen  indigestible  and  undi- 
gested portions  of  the  food  as  well  as  substances  thrown 
off  by  the  mucous  membrane  of  the  intestines.  Thus, 
starch  granules  and  remnants  of  chlorophyll,  muscle 
fibre,  elastic  tissue  fibres,  connective  tissue  fibres,  flakes 
of  casein,  white  blood  corpuscles,  triple  phosphate  crys- 
tals, micro-organisms,  etc.,  may  be  seen.  (Fig.  126.) 


CLINICAL   EXAMINATION.  331 

The  Clinical  Examination  of  the  Stools.  In  order 
to  make  the  clinical  examination  of  the  stools  of  benefit 
and  satisfactory,  we  must  have  a  standard  for  compari- 
son. Schmidt,  of  Dresden,  has  formulated  a  diet  to  meet 
this  requirement  and  it,  or  some  modification,  is  now  in 
general  use  by  those  following  this  line  of  work.  There 
are  two  conditions  for  the  satisfactory  clinical  examina- 
tion of  the  feces. 

1.  A  knowledge  of  what  a  normal  stool  should  be  un- 
der a  certain  diet. 

2.  The  methods  of  examination  must  be  as  simple  as 
possible. 

1.     The  test  diet — The  requirements  are: 

(a)  That  it  must  be  nutritious  enough  to  furnish  calo- 
ries sufficient  for  the  body's  need. 

(b)  It  must  consist  of  such  articles  of  food  as  can 
be  obtained  in  any  household. 

(c)  It  must  contain  a  constant  amount  of  certain  ar- 
ticles, so  that  variation  in  digestion  and  absorption  can 
be  detected  in  the  stool. 

Schmidt's  diet  is  as  follows:  1.5  litres  of  milk,  100 
gms.  Zweiback,  2  eggs,  50  gms.  butter,  125  gms.  very  rare 
or  raw  beef,  190  gms.  potato,  and  gruel  from  60  gms. 
oatmeal  and  20  gms.  sugar. 

This  may  be  divided  as  follows  : 

Breakfast — Two  eggs,  half  liter  or  two  glasses  of  milk, 
one-third  the  amount  of  Zweiback  and  butter,  or  two 
slices  of  well  toasted  bread,  with  butter,  and  the  oat  meal 
and  sugar. 

Dinner — The  steak  and  potatoes  one-third  Zweiback 
and  butter  and  two  glasses  of  milk. 


332  CLINICAL   EXAMINATION. 

Supper — Two  glasses  of  milk  and  the  remainder  of 
toast  or  Zweiback  and  butter. 

The  amounts  of  each  article  should  be  measured  or 
weighed  accurately  and  the  beginning  of  the  test  diet 
marked  by  giving  a  capsule  containing  carmine  or  char- 
coal, preferably  the  latter  because  carmine  would  inter- 
fere with  the  color  reaction  in  case  an  examination  is 
made  for  blood  in  the  stool.  This  diet  should  be  given  for 
several  days.  The  first  black  stool  will  denote  the  length 
of  time  required  for  the  passage  of  food  through  the  gas- 
tro-intestinal  tract.  The  examination  of  the  stool  con- 
sists of  the  following  steps:  The  consistency,  color,  and 
smell  must  be  observed.  Then  a  piece  of  formed  stool 
the  size  of  a  walnut  or  an  equivalent  amount  of  liquid 
feces  is  rubbed  up  in  a  mortar  with  distilled  water  until 
it  is  quite  smooth  and  liquid.  Part  of  this  is  poured 
upon  a  glass  plate  or  a  Petri  dish,  put  over  a  dark  back- 
ground and  examined  in  a  good  light. 

In  normal  digestion,  very  little  should  be  seen  by  the 
raked  eye  except  small  brown  points  (oatmeal),  and  occa- 
sionally sago-like  grains  that  look  like  mucus,  but  which 
the  microscope  shows  to  be  grains  of  potato. 

Pathologically,  there  may  be: 

1.  Mucus  in  large  or  small  flakes  which  is  not  affected 
by  rubbing  up  in  the  mortar.     The  smaller  the  flakes 
the  harder  they  are  to  recognize.     It  appears  as  glassy 
translucent  flakes,  often  stained  yellow  by  bile  pigment. 
If  at  all  doubtful,  the  microscopic  examination  will  clear 
it  up. 

2.  Pus,  blood  if  considerable,  can  be  easily  detected, 
as  can  also  parasites,  stones  and  foreign  bodies. 


CLINICAL,   EXAMINATION.  333 

3.  Remnants  of  muscle  fibre  appear  as  small,  red- 
dish brown  threads  or  small  irregular  lumps.    When  they 
can  be  easily  seen  by  the  naked  eye  and  are  quite  numer- 
ous, it  shows  impairment  of  intestinal  digestion. 

4.  Remnants  of  connective  tissue  and  sinew  from  the 
beefsteak  can  be  detected  from  the  mucus  by  their  tough- 
ness and  whitish-yellow  color.    If  in  doubt,  a  piece  may 
be  put  on  a  slide  with  a  drop  of  acetic  acid  and  examined 
with  the  microscope.     The  connective  tissue  loses  its 
fibrous  structure  while  the  mucus  becomes  more  thread- 
like.    Small  pieces  of  connective  tissue  can  be  found  in 
normal  stools,  but  when  they  are  numerous  and  large 
their  presence  indicates  the  impairment  of  gastric  di- 
gestion. 

5.  Remnants  of  potato  look  like  grains  of  boiled  tapi- 
oca and  may  be  confused  with  mucus.    Any  doubt  of  the 
nature  of  the  particles  can  be  cleared  up  by  the  micro- 
scope. 

6.  Large  crystals  of  acid  phosphate  of  ammonium  and 
magnesium  occur  in  foul  stools,  and  can  be  easily  recog- 
nized by  their  shape  and  chemical  reaction.     (Solubility 
in  all  acids.) 

For  microscopic  examination,  prepare  three  slides 
from  the  liquid  feces. 

The  first — a  drop  of  the  material  to  be  examined  un- 
der high  and  low  power. 

The  second  slide — mix  a  drop  of  the  material  with  a 
drop  of  acetic  acid  (U.  S.  P),  heating  it  to  the  boiling 
point,  then  put  on  the  cover  glass. 

The  third  slide — a  drop  of  the  material  with  a  drop 
of  weak  Lugol  solution  (Iodine  1,  K.  I.  2,  Water  50). 


334 


CLINICAL    EXAMINATION. 


Fig.   127. 
Muscle  Remnants  in  Feces. 

(Leitz  objective  VII.) 
a,  large ;  b,  medium ;  and  c,  small  fragments. 

—From  Schmidt  &  Strasburger. 

Normal  Stool. — Slide  one: 

(a)  Single  small  muscle  fibres,  colored  yellow,  usu- 
ally with  a  cross  striation.     (Fig.  127.) 

(b)  Small  and  large  yellow  crystals  of  salts  of  fatty 
acids. 

(c)  Colorless  particles  of  soap  (gray). 

(d)  Single  potato  cells. 

(e)  Particles  of  oatmeal. 


Fig.  128. 

Haematoidin  Crystals  from  Acholic  Stools. 
(Eye  piece  III,  objective  8  A,   Reichert.) 

— von  Jaksch  &  Cagney. 


CLINICAL   EXAMINATION.  335 

In  the  second  slide  a  general  idea  of  the  fat  content 
of  the  stool  can  be  obtained.  Upon  cooling,  small  flakes 
of  fat  acids  can  be  seen.  The  large  crystals  of  salts  of 
fatty  acids  and  the  soap  are  broken  up  by  the  acetic  acid, 
and  fat  acids  are  liberated.  If  the  slide  is  heated  again 
and  examined  while  hot,  the  fat  acids  will  be  seen  to  run 
together  in  drops,  which,  as  the  slide  cools,  break  sud- 
denly apart. 

In  the  third  slide,  there  should  be  violet-blue  grains 
in  some  of  the  potato  cells,  and  small  single  blue  points, 
probably  fungi  spores. 


Fig.   129. 
Acholic  Stools. 

(Eye   piece   III,   objective    1-15,   oil   immersion,   Reichert,   Abbe's   mirror, 
narrow  diaphragm.) 

— von  Jaksch  &  Cagney. 

Pathologically  There  May  Be. — Slide   1: 

(a)  Muscle  fibre  in  excess,  perhaps  with  yellow  nu- 
clei. 

(b)  Neutral  fat  drops  or  fatty  acids  in  crystals. 

(c)  An  excess  of  potato  cells  with  more  or  less  well 
preserved  contents. 

(d)  Parasite  eggs,  mucus,  connective  tissue,  pus,  etc. 
Slide  2. — Fat  acid  flakes  in  excess. 

Slide  3. — Blue  starch  grains  in  potato    cells    or    free 
oatmeal  cells,  fungus  spores  or  mycelia. 


336  CHEMICAL   EXAMINATION. 

Chemical  Examination. 

The  Reaction. — The  reaction  of  the  stool  is  hard 
to  get  with  litmus  paper,  but  can  be  easily  obtained  by 
dropping  a  little  softened  fecal  matter  into  five  or  ten 
c.c.  of  a  weak,  watery  solution  of  litmus,  shaking  it  and 
noticing  the  change.  It  is  well  to  use  another  test  tube 
with  the  litmus  solution  only,  as  a  control.  The  test 
should  always  be  made  with  freshly  passed  feces,  inas- 
much as  the  reaction  of  the  feces  may  change  upon 
standing. 

The  Sublimate  Test. — Consists  of  taking  of  a  few  c.c 
of  the  liquid  feces  and  mixing  it  with  an  equal  amount  of 
25  per  cent  watery  solution  of  mercuric  chloride.  A  nor- 
mal stool  will  turn  a  pinkish-red,  indicating  the  presence 
of  hydro-bilirubin,  which  will  be  more  intense  the  fresher 
the  material.  A  green  color,  even  if  it  is  detected  micro- 
scopically, is  pathologic  and  indicates  unchanged  bile 
pigment. 

Fermentation  Test. — About  5  gms.  of  fresh  formed 
feces  is  taken,  or  an  equivalent  amount  of  thinner  ma- 
terial. Steele's  Fermentation  Apparatus,  modification 
of  Strasburger's  is  used.  It  is  constructed  of  perforated 
rubber  corks,  bent  glass  tubing,  and  two  test  tubes  of  30 
c.c.  capacity.  (Fig.  130.)  A  small  glass  tube  beam  runs 
up  to  the  top  of  the  test  tube  C  to  allow  for  the  escape  of 
air. 

The  stool  is  rubbed  up  with  sterile  water  and  poured 
into  the  main  bottle  A.  This  is  filled  with  sterile  water; 
tube  B  is  filled  with  water  and  fitted  in  place,  and  tube  C 
is  then  fitted  on  empty.  The  reaction  is  carefully  noted 
before  the  test  is  started.  The  apparatus  is  then  stood 


CHEMICAL  EXAMINATION. 


337 


in  a  warm  place  for  24  hours,  best  in  an  incubator  at  37 
degrees,  (centigrade).  If  gas  forms  by  fermentation  in 
A,  it  will  rise  into  B  and  the  amount  will  be  indicated  by 
the  water  displaced  into  C.  Normally,  the  fermentation 
test  should  show  practically  no  gas,  and  the  original  reac- 


Fig.  130. 
Steele's  Modification  of  Strasburger's  Fermentation  Apparatus. 

It  is  constructed  of  perforated  rubber  corks,  bent  glass  tubing,  and  two 
test  tubes,  each  of  30  cc.  capacity.  The  small  glass  tube  D  runs  up  to  the 
top  of  the  test  tube  C  to  allow  for  the  escape  of  air,  instead  of  the  test 
tube  being  perforated,  as  in  Strasburger's  apparatus. 

— Progressive  Medicine,  December,  1905. 


338  CHEMICAL  EXAMINATION. 

tion  should  be  unchanged  for  24  hours.  If  more  than 
one-third  of  the  tube  C  is  filled,  it  is  pathologic.  If,  then, 
the  reaction  is  decidedly  more  acid,  it  is  a  carbohydrate 
fermentation;  if  alkaline  and  with  a  foul  smell,  it  is  a 
fermentation  of  albumins. 

Estimation  of  Lost  Albumin  or  Albumin  Residue. 

A  qualitative  test  may  be  made  as  follows : 

A  softened  portion  of  the  stool  is  filtered,  the  filtrate 
shaken  with  silicon  and  re-filtered,  then  it  is  saturated 
with  acetic  acid  to  bring  down  the  nucleo-proteids,  after 
filtration  a  drop  of  ferrocyanide  solution  is  added.  A 
decided  precipitate  indicates  albumin. 

It  was  formerly  thought  that  a  positive  test  showed  a 
diminution  of  albumin  digestion,  but  the  work  of  recent 
investigators  would  indicate  that  this  is  not  the  case. 
Under  pathologic  conditions,  the  nucleo-proteids  may  be 
decidedly  increased,  although  their  presence  is  not  char- 
acteristic of  any  particular  disease.  Other  forms  of  al- 
bumin are  rarely  found  in  the  feces,  even  after  the  inges- 
tion  of  excessive  amounts.  The  occurrence  of  albumin 
in  the  feces  of  adults  is  almost  always  associated  with 
diarrhoea  and  usually  with  an  excessive  formation  of 
mucus.  It  usually  is  serum  albumin  much  less  frequently 
albumoses.  Such  "lost  albumin"  in  the  stools  indicate 
severe  anatomical  changes  in  the  bowel  but  usually  not 
disturbance  of  absorption.  The  albumin  under  these  cir- 
cumstances conies  from  the  intestinal  wall,  and  sometimes 
a  part  of  them  may  be  digested  by  the  intestinal  ferments 
into  albumoses. 


CLINICAL,  SIGNIFICANCE  OF  TEST.  339 

Clinical  Significance  of  Test. 

Mucus. — There  are  two  conditions  in  which  the 
presence  of  mucus  in  the  stools  has  no  significance :  When 
hard,  dry  masses  of  feces  are  covered  with  thin  mucus, 
without  evidence  of  rectal  inflammation,  and  when  it  is 
discharged  in  casts,  the  so-called  mucus  colic.  Otherwise 
it  indicates  inflammation  of  the  intestinal  mucous  mem- 


'Wf*€s»v£ 

•J'i^iii^W'- 


Fig.  131. 
Mucus  Shreds. 

—  From  Schmidt  &  Strasburger. 

brane.  If  it  is  densely  impregnated  with  bacteria,  food 
remnants,  and  detritus  the  origin  of  the  inflammation  is 
probably  high  up  in  the  intestine.  (Figs.  131-132.) 

Bilirubin  discoloration  affords  no  certain  evidence  of 
inflammation  of  the  small  intestine,  but  the  presence  of 
bilirubin  granules  and  crystals  in  a  cellular  arrange- 
ment is  suggestive. 

The  presence  of  semi-digested  cells  or  of  their  nuclei 
indicates  an  origin  high  up  in  the  bowel. 

The  presence  of  hyaline  cells  favors  the  assumption 
that  an  inflammation  of  the  colon  exists. 

Bile  Pigment. — A  green  color  of  part  or  all  of  a 
stool,  by  the  sublimate  test,  is  pathologic,  except  in  chil- 


340 


CLINICAL  SIGNIFICANCE  OF  TEST. 


dren.  It  means  a  too  short  period  of  passage  through  the 
intestine,  and  that  time  for  a  normal  reduction  process 
of  the  bilirubin  into  hydro-bilirubin  was  lacking.  A  nor- 


Fig.  132. 
Mucus  Shreds  After  the  Addition  of  Acetic  Acid. 

— Urine  and  Feces  in  Diagnosis:     Hensel,  Weil,  and  Jelliffe. 

mal  fresh  stool  will  give  a  pink  color  with  mercuric  chlo- 
ride. If  a  color  reaction  of  any  kind  is  absent,  it  indi- 
cates a  very  fat  stool,  or  an  absence  of  bile  in  the  intes- 
time.  (Fig.  129.) 

The  assumption  of  the  temporary  stoppage  of  the  bile 
does  not  account  for  all  of  the  cases  of  colorless  feces 
which  do  not  darken  on  exposure.  The  pathologic  con- 
ditions in  which  colorless  feces  without  jaundice  may  oc- 
cur comprise  defective  supply  of  bile  to  the  duodenum, 
intestinal  catarrh,  tuberculous  abdominal  disease,  malig- 
nant disease  of  the  intestine,  septic  diseases  (especially 
those  which  affect  the  abdomen),  chlorosis  and  leukemia. 


CLINICAL  SIGNIFICANCE  OF  TEST.  341 

Fat. — It  will  need  a  little  practice  to  tell,  by  the  use 
of  the  diet,  whether  there  is  an  increase  of  fat  in  the 
stool.  As  the  normal  amount  of  fat  in  the  feces  varies 
between  wide  limits  only  a  considerable  excess  of  fat  can 
be  detected. 

Remnants  of  Meat. — Normally  there  should  be  only 
microscopic  particles  of  connective  tissue  and  muscle 
fibre.  An  excess  of  either  is  often  visible  to  the  naked 
eye,  but  need  not  be  macroscopic  to  be  pathologic. 

Excess  of  Connective  Tissue  indicates  insufficient 
gastric  digestion,  because  such  fibrous  tissue  is  only 
digested  by  the  gastric  juice.  The  meat  should  be  rare,  to 
give  this  test  its  full  value.  If  motility  is  increased,  there 
may  be  an  excess  of  this  in  hyper-acidity. 

Excess  of  Undigested  Muscle  Fibre,  indicates  intes- 
tinal indigestion  and  probably  means  trouble  in  the  up- 
per part  of  the  small  intestine ;  but  whether  the  trouble  is 
in  the  trypsin  of  the  pancreatic  secretion,  or  the  activat- 
ing principle  (entero-kinase)  of  the  intestinal  juice,  or 
in  increased  peristalsis,  we  can  only  judge  from  other 
symptoms.  When  the  gastric  juice  fails  to  digest  away 
the  frame  work  of  the  muscle  fibre,  giving  the  intestinal 
juices  no  chance  to  do  its  work,  connective  tissue  and 
muscle  fibre  are  often  found.  This  occurs  often  in  acute 
gastric  catarrh. 

Pathologic  Carbohydrate  Fermentation  means  poor 
starch  digestion  and  indicates,  as  a  rule,  disturbance  in 
the  small  intestine  and  usually  is  due  to  insufficiency  of 
the  succus  entericus. 

Pathologic  Albumin  Fermentation  means  a  large  resi- 
due of  albumin  in  the  feces  and  indicates  usually  some 


342  CLINICAL  SIGNIFICANCE  OF  TEST. 

anatomical  change  in  the  mucous  membrane  of  the  small 
intestine. 

Pits  can  be  rarely  recognized  in  the  stool  unless  it 
comes  from  the  lower  part  of  the  large  bowel ;  if  it  comes 
from  high  up  in  the  intestine  it  is  rapidly  changed. 

Blood  in  the  Stools. — The  presence  of  blood  in 
such  quantities  to  be  visible  is  considered  in  Chapter  II, 
so  I  will  only  consider  the  so-called  occult  blood  in  the 
stools.  The  presence  of  occult  bleeding  from  the  gastro- 
intestinal tract  is  a  symptom  of  much  importance,  pro- 
viding various  sources  of  error  can  be  eliminated.  It 
has  the  same  clinical  significance  as  visible  hemorrhage 
and  its  presence  is  of  decided  diagnostic  value,  chiefly 
in  the  detection  of  gastric  or  duodenal  ulcer,  or  gastro- 
intestinal cancer,  because  it  occurs  with  considerably 
more  regularity  and  frequency  in  these  affections  than  in 
any  other  condition  of  the  gastro-intestinal  tract. 

The  value  of  this  sign  depends  entirely  upon  the  care 
with  which  the  various  sources  of  error  are  eliminated, 
and  if  the  reaction  is  positive  will  be  of  value  in  the  diag- 
nosis of  cancer  or  ulcer  of  the  gastro-intestinal  tract  only 
when  sources  of  bleeding  that  have  no  significance  are 
excluded.     On  the  other  hand,  after  repeated  examina- 
tions, occult  blood  is  not  found,  then  cancer  or  ulcer  can 
be  excluded.    Since  the  test  is  very  sensitve  (very  small 
amounts  can  be  detected),  the  chance  for  error  in  deter- 
mining the  origin  of  the  hemorrhage  is  greater  than  in 
large  and  visible  hemorrhages.    Observations  have  shown 
a  positive  reaction  in  the  feces  on  the  ingestion  of  0.5 
gms.  of  blood.    It  is  possible  to  exclude  the  source  of  the 
blood  when  in  the  lower  bowel  by  the  use  of  the  procto- 


TESTS  FOR  OCCULT  BLOOD.  343 

scope,  etc.  Tuberculous  ulcer,  typhoid  fever,  hemor- 
rhoids, fissure  and  purpura  can  be .  easily  excluded ; 
other  conditions,  however,  e.  g.  cirrhosis  of  the  liver  with 
slight  symptoms  may  be  the  cause  of  error.  Bed  beets, 
carmine,  swallowed  blood  from  any  cause,  hemoptysis, 
epistaxis,  menstruation,  cirrhosis  of  the  liver,  purpura, 
benign  stenosis  with  stagnation,  tuberculous  enteritis, 
cancer  of  the  gastro-intestinal  tract,  gastric  or  duodenal 
ulcer,  typhoid  ulcer,  hemophilia,  hemorrhoids,  fissure, 
and  fistula  of  the  rectum  is  a  partial  list  of  conditions 
which  may  give  a  positive  reaction  with  the  various  tests. 

When  testing  for  occult  blood  it  is  best  to  have  the 
patient  on  a  diet  free  from  meats  and  meat  juices  and  to 
give  a  good  sized  capsule  of  charcoal;  the  first  black 
stool  will  mark  the  feces  following  the  meat-free  diet. 

A  number  of  different  tests  are  used  for  the  detection 
of  occult  blood ;  probably  the  Weber  test,  with  its  various 
modifications  is  the  one  most  employed.  It  is  well,  how- 
ever, to  use  a  control  test,  preferably  Klunge's  aloin 
test.  If  both  tests  give  a  positive  reaction,  there  is  no 
doubt  but  that  there  is  blood  in  the  stools.  The  latter  is 
not  liable  to  be  obscured  by  bile  pigments  or  chlorophyll, 
in  the  ethereal  extract,  and  is  extremely  delicate. 

Webber's  Test. — Take  2  or  3  gins,  feces,  mix  thor- 
oughly with  20  c.c  of  water;  extract  with  20  c.c  ether  to 
remove  fats.  Then  use  one-third  the  volume  of  acetic 
acid  and  shake  well ;  add  10  c.c  of  ether  and  shake  well. 
If  ether  doesn't  come  to  the  top  soon,  add  a  few  drops 
of  absolute  alcohol.  To  2  c.c  of  the  ethereal  extract,  add 
10  drops  freshly  prepared  tr.  guaiac  and  10  to  20  drops 
of  ozonized  turpentine.  Care  must  be  taken  that  all  uten- 


344  TESTS  FOB  OCCULT  BLOOD. 

sils  are  absolutely  clean  and  free  from  water.  If  blood  is 
present,  an  intense  blue  color  appears,  gradually  assum- 
ing a  reddish  violet  tint. 

Klunge's  Aloin  Test. — Take  a  small  quantity  of 
aloin,  mix  with  3  to  5  c.c  of  70  per  cent  alcohol.  Four  to 
five  c.c  of  acetic  acid  ethereal  extract  is  tried  with  20  to 
30  drops  of  ozonized  turpentine  and  10  to  15  drops  of  the 
aloin  solution.  If  blood  is  present  a  bright  red  color  ap- 
pears which  turns  to  a  cherry  red  on  standing.  If  blood 
is  not  present,  a  yellow  color  remains  for  an  hour  or  two, 
then  becomes  pink.  It  may  take  15  or  20  minutes  to  get  a 
positive  reaction. 

Holland's  Modification  of  Webber's  Test. — Instead 
of  using  ozonized  turpentine,  Holland  used  sodium  per- 
borate (Sherring)  in  tablet  form;  a  few  drops  of  the 
acetic  acid  ether  mixture  is  placed  upon  a  small  piece  of 
tablet  of  perborate  of  sodium  and  a  drop  or  two  of  the 
tincture  of  guaiac  is  cautiously  brought  into  contact  with 
it,  preferably  on  a  white  plate.  If  blood  is  present,  the 
perborate  turns  blue  in  a  few  minutes  and  remains  blue 
until  the  drying  of  the  tincture  of  guaiac  leaves  a  yellow 
residue  which  changes  the  blue  to  green.  If  the  propor- 
tion of  blood  is  small  the  perborate  turns  a  pale  blue, 
which  turns  green  as  the  guaiac  dries. 

Benzidin  Test. — A  little  benzidin  and  about  2  c.c 
glacial  acetic  acid  are  shaken  up  together  and  set  aside 
for  the  benzidin  to  dissolve.  A  piece  of  feces  the  size 
of  a  bean  is  stirred  into  a  test  tube  about  one-fifth  full 
of  water ;  the  tube  is  plugged  with  cotton  and  the  suspen- 
sion of  fecal  matter  is  heated  to  a  boiling  point  over  a 
flame.  About  10  or  12  drops  of  the  concentrated  benzi- 


GALLSTONES. 


345 


din  solution  are  poured  into  another  test  tube,  from  2.5 
to  2  c.c  of  a  three  per  cent  solution  of  peroxide  of  hydro- 
gen added.  One  or  two  drops  of  the  boiled  suspension  of 
feces  is  then  added  to  this  mixture.  If  blood  is  present 
in  the  feces,  this  brownish  fluid  turns  green  or  blue;  the 
more  blood  the  more  the  test  inclines  to  blue.  The  color 
reaction  occurs  within  two  minutes  in  the  presence  of 
blood  and  turns  to  a  dirty  purple  in  five  to  fifteen  minutes. 
If  there  is  no  blood  present  the  dirty  brown  color  remains 
unaltered. 


Fig.  133. 
Gallstones. 

Gall  Stones. — In  cases  of  colicky  abdominal  pain, 
the  feces  should  always  be  examined  for  biliary 
concretions.  The  best  way  to  search  for  gall 
stones  is  to  put  the  feces  in  a  fine  sieve  and 
wash  the  stool  with  running  water  from  a  faucet,  if  pos- 
sible. The  concretions  vary  in  size  from  as  small  as  the 
head  of  a  pin  to  the  size  of  a  pigeon's  egg.  They  may 
be  seen  as  small  crumbling  masses  or  as  hard  stones 
presenting  an  irregular  contour  or  as  smooth  facets. 
(Fig.  133.)  The  larger  stones  are  not  passed  by  the  bowel 
unless  perforation  has  occurred  into  the  intestine.  The 
composition  of  the  calculi  varies.  Some  are  composed  of 
cholesterin;  some  of  inspissated  bile,  and  others  of  cal- 
careous salts.  Those  composed  of  cholesterin  are  the 


346  ANIMAL  PARASITES. 

most  common  and  are  somewhat  soft  and  white,  greyish, 
bluish  or  greenish  in  color.  I  think  that  the  consensus  of 
opinion  inclines  to  the  belief  that  the  nucleus  of  the  ma- 
jority of  gall  stones  is  clumps  of  bacteria,  either  bacilli 
coli  communis  or  typhoid  bacilli,  although  it  may  be  com- 
posed of  earthy  sulphates  or  phosphates.  Calculi  which 
consist  largely  of  biliary  pigments  are  brown  in  color, 
hard  and  heavier  than  water;  those  composed  of  calca- 
rious  salts  are  generally  irregular  and  rough. 

Intestinal  Concretions,  or  Enteroliths,  are  rare.  At 
times  their  nucleus  consists  of  some  foreign  body  like  a 
fruit  seed,  upon  which  calcium  and  magnesium  salts  have 
become  deposited. 

Intestinal  Sand  is  hard,  gritty,  pale  brown  to  black  in 
color,  readily  sinks  in  water,  and  is  usually  composed  of 
the  salts  of  calcium  magnesium  and  ammonium.  Some- 
times silica  is  present. 

Animal  Parasites. 

Pathologic  Forms. — Of  the  protozoa,  the  amoebae 
(see  Chapter  XIII),  are  the  most  important  in  the  etio- 
logy of  intestinal  disease.  It  is  possible  to  find  amoebae 
in  the  stools  of  perfectly  normal  individuals,  and  they 
increase  in  number  as  the  stools  become  more  alkaline  in 
reaction. 

In  certain  forms  of  dysentery  the  amoebae  coli  occur 
in  the  stools  in  enormous  numbers,  chiefly  embedded  in 
the  mucus.  They  are  also  found  on  pathologic  exami- 
nation in  the  ulcers  in  the  intestines.  In  examining  the 
stool  must  be  fresh,  as  the  amoebae  very  rapidly  die  off 
in  a  stool  that  has  been  preserved  but  a  few  hours.  A 
particle  of  mucus,  preferably  blood  streaked,  is  taken 


PROTOZOA. 


347 


from  a  fresh  stool  and  placed  on  a  chemically  clean  slide 
or  better,  a  warm  stage.  In  adjusting  the  cover  glass, 
a  horse  hair  or  some  similar  object  should  be  placed  be- 


Fig.  134. 
The  Amoeba  Coli. 

— Clinical  Diagnosis:     Simon. 

tween  it  and  the  slide,  in  order  not  to  crush  the  organisms 
or  interfere  with  their  locomotion.  Examine  with  a  low 
power  microscope.  They  are  from  10  to  50  micro-mil- 
limetres in  size.  When  at  rest,  their  outline  is,  as  a  rule, 
circular  or  ovoid;  but  when  in  motion,  they  present  one 
or  more  arm-like  prolongations,  'the  pseudopods."  The 
protoplasm  can  be  differentiated  into  a  translucent,  ho- 
mogenous ectosarc  or  mobile  portion  and  a  granular  en- 
dosarc  containing  the  nucleus,  vacuoles,  and  granules. 
(Fig.  134.)  As  a  rule  one  or  two  large  vacuoles  are  pres- 
ent, the  edges  of  which  are  not  infrequently  surrounded 
by  fine,  dark  granules. 

Balantidium  Coli. — Another  form  of  protozoon,  that 
is  an  etiologic  factor  in  certain  forms  of  dysentery  is  the 
balantidium  coli.  This  organism  is  a  harmless  inhabitant 

23 


348 


WORMS. 


of  the  colon  of  the  pig,  and  it  is  supposed,  is  transferred 
to  human  beings  through  sausages.  (Fig.  135.)  The  para- 
site is  of  oval  shape,  60  to  100  microns  long  and  50  to  70 


Fig.  135. 

Balantidium  Coli. 

2.     1    and    2    stages    of    division.      3    Conjugation.      (After    Leuckart.) 

— Progressive  Medicine,  December,  1905. 

broad,  and  is  covered  with  cilia  that  are  in  rapid  motion 
when  the  organism  is  alive.  Ectosarc  and  endosarc  are 
sharply  differentiated.  The  endosarc  is  granular  and 
contains  a  kidney  shaped  nucleus,  generally  two  contrac- 
tile vacuoles  and  granular  detritus.  Motion  is  so  rapid 
that  it  cannot  be  followed  under  the  microscope.  The 
protozoon  dies  very  quickly  and  undergoes  fragmenta- 
tion. 

There  are  other  forms  of  protozoa,  but  their  role  in  the 
etiology  of  intestinal  diseases  is  not  definitely  settled. 

Worms. 

The  diagnosis  of  helniinthiasis  from  the  stools  may  be 
very  easy  or  it  may  require  considerable  painstaking  re- 
search. If  segments  of  the  taenia  pass  in  the  stools,  the 
diagnosis  is  quite  evident.  In  other  cases,  a  diagnosis 
can  only  be  made  by  finding  the  ova  in  the  feces.  To 
examine  for  the  ova,  take  a  small  amount  of  feces  from 


WOEMS. 


349 


different  parts  of  the  stool,  dilute  it  very  much  with 
sterile  water  and  centrifuge  repeatedly.  After  each  cen- 
trifugalization,  the  supernatent  dirty  water  is  thrown 
away  and  fresh  water  is  added,  the  whole  shaken  up  and 
again  placed  in  the  centrifuge,  this  to  be  repeated  five 
or  six  times.  In  this  way  all  bacteria,  free  coloring  mat- 
ter, light  vegetable  matter,  etc.,  are  gotten  rid  of  and 
only  heavier  particles  including  any  ova  that  may  be 
present,  will  remain  and  can  be  easily  and  satisfactorily 
examined  under  a  low  power  of  the  microscope.  There 
is  the  left  no  obscuring  cloud  of  bacteria  or  fine  granular 
debris,  but  instead  each  ovum,  or  muscle  fibre,  or  crystal 
stands  out  sharp  and  clear. 


Fig.  136. 
Ascaris  Lumbricoides. 

a,  The  Worm;  b,  Head;  c,  Egg;  a,  half  natural  size;  b,  slightly  magni- 
fied; c,  eye  piece  I,  objective  8a.  Reichert. 

— Clinical   Diagnosis:    vori  Jaksch   &  Cagney. 


350 


NEMATODES. 


Nematodes.  Nematodes  are  round  worms.  Those 
found  in  the  human  being  are: 

1.  Ascaris  Lumbricordes  is  the  most  common  parasite 
of  the  human  intestinal  canal.  They  are  found  chiefly 
in  the  small  intestines  but  may  find  their  way  into  the 
stomach,  the  bile  passages,  or  out  at  the  anus.  Clumps 
of  them  have  been  known  to  cause  intestinal  obstruction. 


Fig.  137. 

Oxyuris  Vermicularis. 

a,  sexually  mature  female;  b,  female  filled  with  eggs;  c,  male.    Magni- 
fication, 10.     (After  Heller,  from  Ziegler.) 


NEMATODES. 


351 


The  worm  is  cylindrical,  the  male  being  from  10  to  25 
c.m.  in  length,  the  female  from  25  to  40  c.m.  The  head 
consists  of  three  projections  or  lips,  which  are  provided 
with  suckers  and  fine  teeth.  The  tail  end  of  the  male  is 
rolled  up  on  its  ventral  surface  like  a  hook  and  is  pro- 
vided with  papillae.  The  genital  aperture  of  the  female 
is  situated  directly  behind  the  anterior  third  of  the  body. 
The  eggs  are  yellowish  brown  in  color,  almost  round,  and 
measure  0.06  mm.  by  0.07  mm.  in  size.  They  are  sur- 
rounded by  an  irregular  albuminous  envelope  which  is 
covered  by  a  tough  shell ;  the  contents  are  coarsely  granu- 
lar. (Fig.  136.) 

2.  Oxyuris  Vermicularis. — (Common  thread  worm, 
teat  worm,  pin  worm,  etc.),  is  a  very  frequent  parasite, 
especially  in  young  children,  often  passing  from  the  anus 
into  the  vulva  in  female  children  and  setting  up  con- 
siderable irritation  in  the  vagina.  The  male  is  4  mm.; 
the  female  10  mm.  long.  At  the  head  three  lip-like  pro- 


Fig.  138. 

Oxyuris  Vermicularis. 

I.  Oxyuris  vermicularis ;  a,  Male ;   b,  Female ;   natural  size.    2,  Magnified. 
— Urine  and  Feces  in  Diagnosis:   Hensel,  Weil  &  Jelliffe. 


352 


NEMATODES. 


jections  with  lateral  cutieular  thickenings  may  be  seen. 
The  tail  of  the  male  is  provided  with  six  pairs  of  papillae 
and  the  female  with  two  uteri.  The  eggs  are  0.05  by  0.02 
to  0.03  mm.  in  size,  and  covered  with  a  membrane  show- 
ing a  double  or  triple  contour.  In  the  interior,  which  is 
coarsely  granular,  the  embryo  are  contained.  The  ova 
do  not  occur  in  the  feces.  (Figs.  137-138.) 

Anchylostomum  Duodenale,  or  Dochimus  Ditodenn- 
lis,  or  Strongylus  Duodenalis  is  generally  described  in 
America  as  Uncinaria.  It  was  formerly  supposed  that 
this  parasite  was  found  only  in  the  Old  World  and  only 
brought  into  this  country,  but  it  has  been  demonstrated 
that  there  are  many  endemic  cases  in  our  Southern 
States. 


Fig.  139. 
Anchylostoma   Duodenale. 

a,  Male   (natural  size). 

b,  Female  (natural  size). 

c,  Male   (magnified). 

d,  Female  (magnified). 

c,     Head    (eyepiece   II,   objective   C,   Zeiss). 
Eggs. 


f, 


— von  Jaksch  &  Cagney. 


NEMATODES.  353 

There  are  certain  differences  between  the  American 
and  Old  World  parasite. 

Stiles,  in  Bulletin  No.  10  Hygienic  Laboratory,  U.  8. 
Public  Health  and  Marine  Hospital  Service,  gives  the 
following  description:  Uncinaria  duodenalis — -"The  Old 
World  hook  worm:  Body  cylindrical,  somewhat  attenu- 
ated anteriorly;  buccal  cavity  with  two  pairs  of  ventral 
teeth  curved  like  hooks,  and  one  pair  of  dorsal  teeth 
directed  backward;  dorsal  rib  not  projecting  into  cavity. 
Male  8  to  11  mm.  long,  caudal  bursae  with  dorso-median 
lobe  and  prominent  lateral  lobes  united  by  a  ventral 
and  slender.  Female,  10  to  11  mm.  long;  vulva  at  or  near 
Dosterior  third  of  body.  Eggs  ellipsoid  52  to  60  micro- 
millimetres  by  32  micromillimetres  laid  in  segmentation. 
Development  direct  without  intervening  host."  (Fig.  139.) 

Uncinaria  Americana— "The  New  World  hook  worm 
of  man,  body  cylindrical,  somewhat  attenuated  anteri- 
orly, buccal  capsule  with  a  dorsal  pair  of  prominent  semi- 
lunar  plates  or  lips  and  a  ventral  pair  of  slightly  de- 
veloped lips  of  same  nature ;  dorsal  conical  median  tooth 
projects  prominently  into  buccal  cavity.  Male  7  mm. 
long,  caudal  bursae  with  short  dorso-median  lobe  which 
often  appears  as  if  it  were  divided  into  two  lobes,  and 
with  prominent  lateral  lobes  united  ventrally  by  an  indis- 
tinct ventral  lobe ;  common  base  of  the  dorsal  and  dorso- 
lateral  rays  very  short;  dorsal  ray  divided  to  its  base, 
its  two  branches  being  widely  divergent,  and  their  tips 
being  bipartite;  spicules  long  and  slender.  Female  9 
to  11  mm.  long;  vulva  in  anterior  half  of  body  but  near 
equator.  Eggs  ellipsoid,  64  to  76  micromillimetres  long 
by  36  to  40  micromillimetres  broad,  in  some  cases  parti- 


354  NEMATODES. 

ally  segmented  in  utero;  in  others  containing  a  fully 
developed  embryo  oviposited."  The  eggs  of  the  Ameri- 
can species  are  much  larger  than  those  of  the  Old  World 
species.  The  eggs  have  a  transparent  shell  with  a  lineal- 
contour  and  are  often  found  in  enormous  quantities  in 
the  feces.  A  rather  peculiar  fact  that  the  ova  of  uncina- 
ria,  although  sticking  closely  to  the  glass  slide,  do  not 
seem  to  adhere  to  any  of  the  other  constituents  of  the 
stool.  When  a  drop  of  washed  sediment  feces  is  allowed 
to  remain  on  the  slide  for  a  few  minutes  and  then  gently 
immersed  in  water  and  examined  microscopically,  the 
eggs  are  found  adhering  to  the  slide  and  all  else  has  been 
washed  away.  In  suspected  cases  where  the  diagnosis 
is  difficult,  a  full  dose  of  thymol  may  make  it  clear ;  caus- 
ing the  appearance  in  the  stool  of  the  parasite  which  ap- 
pears as  a  thread-like  body,  a  half  to  three-quarters 
of  an  inch  long,  grayish  red  in  color.  Its  habitat  is  the 
jejunum  and  duodenum.  Infection  takes  place  through 
contaminated  drinking  water. 

For  persons  who  are  not  in  a  position  to  make  a  micro- 
scopic examination,  the  blotting  paper  test  will  be  found 
very  useful.  To  make  the  test  use  only  fresh  feces.  Place 
an  ounce  or  more  of  the  stool  on  a  piece  of  white  blotting 
paper,  allowing  it  to  remain  for  20  to  60  minutes ;  remove 
the  feces  and  examine  the  color  of  the  stain.  In  about  75 
per  cent  of  the  cases  of  medium  or  severe  uncinariasis. 
the  stain  is  a  reddish  brown  resembling  somewhat  a 
blood  stain.  In  making  this  test  on  anemic  patients, 
hemorrhoids  must  be  excluded. 

Trichocephalus  Dispar,  or  "Whip  Worm,"  frequent 
in  most  parts  of  the  world,  gets  its  name  from  being 


NEMATODES. 


355 


formed  like  a  whip,  the  lash  end  being  the  head  end, 
while  the  tail  end  is  very  much  thicker.  The  male  meas- 
ures 46  mm.  and  the  female  50  mm.  in  length.  The  eggs 


Fig.  140. 
Trichocephalus  Dispar. 

a.   Male;    b.   Female;    c.   Eggs;   a.   b.,   slightly   magnified;   c.    (eye  piece 
II,  objective  8  a,  Reichert.) 

— von  Jaksch  &  Cagney. 

are  brownish  in  color  0.05  by  0.06  mm.  in  size,  presenting 
a  double  contoured  shell  with  a  depression  at  each  end, 
closed  by  a  lid.  The  contents  are  coarsely  granular.  Its 
habitat  is  in  the  cecum;  the  living  worm  is  rarely  found 
in  the  feces.  (Fig.  140.) 

Trichina  Spiralis. — The  male  is  1.5  mm.  in  length, 
and  the  female  3  mm.  The  male  has  four  prominent  pa- 
pillae, situated  between  the  conical  protuberances  at  the 
extremity.  The  female's  sexual  organs  consist  of  a 
tubular  ovary  which  is  placed  at  the  hinder  part  of  the 
body  and  a  tubular  uterus  with  which  the  ovary  communi- 
cates in  front.  Impregnation  takes  place  in  the  intes- 
tine. The  eggs  develop  into  embryos  while  still  in  the 


356 


NEMATODES. 


uterus,  and  the  newly  born  parasite  almost  immediately 
perforates  the  intestine  and  becomes  embedded  in  tke 
muscles  of  its  host.  The  mode  of  infection  is  through 


Fig.  141. 
Trichinae. 

a.     Male,   and    b.   Female    Intestinal     Trichinae,    slightly   magnified ;    c. 
Trichina  of  muscle   (eye-piece  III,  objective  IV,  Reichert.) 

— von  Jaksch  &  Cagney. 

imperfectly  cooked  pork.  Rarely  is  the  parasite  found  in 
the  stools.  In  suspected  cases  an  anthelmintic  may  cause 
the  expulsion  of  the  mature  worm  in  the  stool.  Eosino- 
philia  is  a  constant  accompaniment  of  the  presence  of 
trichina.  (Fig.  141.) 

Anguillula  Intestinalis,  is  2.25  mm.  in  length  and 
0.04  mm.  in  thickness  at  its  middle.  It  has  a  triangular 
mouth  closed  by  three  lips.  Its  vulva  lies  at  the  junction 


CE3TODES. 


357 


of  the  middle  with  the  posterior  third.  Its  habitat  is 
the  small  intestines.  The  eggs  resemble  those  of  anchylo- 
stoma  duodenalis  but  are  longer,  more  elliptical  and 


Fig.  142. 
Anguillula   Stercoralis. 

a.     Female;  b.     Male;    c.  Head   (eye-pice  II,  objective  8  a,  Reichert.) 

— von  Jaksch  &  Cagney. 

pointed  at  the  poles.  In  recent  stools  the  larvae  alone 
can  be  seen.  When  sexually  mature,  it  is  known  as  an- 
guillula  stercoralis;  the  body  is  round;  it  shows  faint 
traces  of  transverse  striation.  The  head  is  the  form  of  a 
blunt  cone  and  sessile  on  the  body,  and  is  furnished  with 
two  lateral  jaws,  each  bearing  a  pair  of  teeth.  The  male 
is  0.88  mm.  and  the  female  1.2  mm.  long.  Little  is  known 
concerning  the  manner  of  infection.  Thayer  reported  the 
first  case  of  infection  by  this  worm  in  the  U.  S.  (Fig.  142.) 
Cestode  Worms.  Cestodes  are  popularly  known 
as  tape-worm.  Externally  they  are  long,  flattened  seg- 
mented worms.  The  head  is  derived  from  the  embryo 


358  CESTODES. 


contained  in  the  flesh  of  the  various  domestic  animals 
which  are  used  as  food.  By  budding  it  gives  rise  to  all 
of  the  succeeding  segments  which  are  morphologically 
the  same,  diminishing  in  size  toward  the  head. 


Fig.  143, 
Head  of  Taenia  Solium. 

Head  of  Taenia  Solium.     x45.     (Leuckart.) 

Taenia  Solium. — The  tape  worm  derived  from  pork 
may  be  two  to  three  meters  long.  Head  quadrilateral, 
about  as  large  as  a  pin-head ;  it  has  four  prominent  suc- 
torial discs,  usually  pigmented  and  between  them  a 
rounded  elevation  which  is  surrounded  with  about  26 
booklets  of  different  sizes,  and  is  dark  in  color.  This  is 
succeeded  by  a  delicate  thread-like  neck  about  one  inch 
in  length  and  unjointed.  The  segments  or  proglottedes 
are  short  and  relatively  broad  near  the  neck ;  the  mature 
segments'  average  length  is  from  9  to  10  mm.  and  breadth 
6  to  7  mm.  and  contains  a  uterus  having  five  to  seven 
branches.  The  ova  are  round  and  of  a  brownish  color 
and  surrounded  with  a  thick  radially  striated  membrane ; 
in  their  interior  the  booklets  of  the  embryos  can  usually 
'be  made  out.  (Fig.  143.) 

Taenia  Saginata  (Medio  Cannulata). — The  most  fre- 
quent tape  worm  of  Europe  and  America,  infection  tak- 
ing place  through  measlv  beef.  It  is  from  4  to  8  metres 


CESTODES. 


359 


long.  The  head  is  surrounded  with  four  large  and  usu- 
ally black  pigmented  suckers,  but  is  not  provided  with' 
rostellum  and  is  without  a  circle  of  booklets.  Segments 


Fig.  144. 

Taenia  Saginata. 

a.  Natural  size. 

b.  Head    much    enlarged. 

c.  Ova  much  enlarged. 

— Clinical  Diagnosis:     Simon. 


360 


CESTODES. 


are  quite  thick  and  opaque,  and  each  is  provided  with  a 
very  much  branched  uterus  which  opens  laterally.  The 
ova  are  elliptical  in  form,  of  a  brown  color,  and  usually 
enclosed  in  a  distinct  vitelline  membrane.  In  the  interior 
the  embryos  are  seen  embedded  in  a  brown  granular 
material.  (Fig.  144.) 

Taenia  Nana. — Occurs  rarely  in  America,  mostly  in 
Southern  Italy.  It  is  7  to  15  mm.  long.  It  occurs  in  large 
numbers,  and  is  usually  located  in  the  lower  part  of  the 
ileum.  It  has  four  suckers  and  a  crown  of  booklets.  Tht 
segments  are  of  a  yellowish  color  and  about  four  times  as 
broad  as  long.  The  uterus  is  oblong  and  contains  numer- 
ous ova,  having  two  distinct  membranes.  In  the  interior 
of  the  egg,  may  be  seen  the  embryo  already  provided  with 
five  or  six  booklets.  Infection  probably  occurs  from  man 
to  man.  The  parasites  may  be  present  in  great  numbers 
in  the  intestines,  producing  severe  nervous  symptoms 
such  as  epileptic  seizures,  insensibility,  mental  derange- 
ments, etc. 


II 


Fig.  145. 
Head  of   Bothriocephalus  Latus. 

(Eye-piece  III,  objective  IV,  Reichert).  a.  Seen  on  edge;  b.  Seen  on 
the  flat;  c.  Proglottides ;  d.  Eggs. 

— von  Jaksch  &  Cagney. 

Bothriocephalus  Latus. — The  longest  of  the  human 
tape  worms  has  been  found  in  the  United  States  in  only 
a  few  imported  cases.  The  larvae  have  been  found  in 


CHARACTER  OF  FECES  IN  INTESTINAL,  AFFECTIONS.        361 

various  fishes.  It  is  from  five  to  eight  metres  long  and 
tapers  toward  both  extremities.  The  largest  segments 
measure  3.5  mm.  in  length,  10  to  12  mm.  in  breadth. 
The  head  is  ovoid,  25  mm.  long  and  1.0  mm.  broad,  some- 
what flattened  and  provided  in  each  lateral  aspect  with  a 
groove-like  sucking  apparatus.  The  uterus  is  a  slightly 
convoluted  canal.  The  eggs  are  ovoid  0.07  mm.  by  0.045 
mm.  and  possess  a  thin  brown  capsule  and  open  by  a 
small  lid  at  one  end.  This  parasite  may  be  the  cause  of 
severe  anemia.  (Fig.  145.) 

Character  of  Feces  in  Certain  Intestinal  Affections. 

Acute  Intestinal  Catarrh. — This  follows  the  inges- 
tion  of  excessive  quantities  of  normal  food  or  tainted 
food,  beer  and  certain  poisons,  acids  or  alkalies,  arsenic, 
corrosive  sublimate,  etc.,  when  taken  in  proper  quanti- 
ties ;  also  find  it  in  cholera  nostras,  typhoid  fever,  severe 
malaria,  also  in  diseases  of  heart,  lungs  and  liver  due  to 
disturbance  in  circulation.  The  frequency  of  the  stools 
depends  largely  upon  the  seat  of  the  lesion ;  involvement 
of  the  large  intestine,  especially  the  transverse  and  de- 
scending colon  causing  the  bowels  to  move  more  fre- 
quently than  trouble  higher  up.  There  may  be  from  10  to 
15  passages  a  day.  On  the  other  hand,  isolated  catarrh 
of  the  small  intestine  may  exist  without  giving  rise  to 
diarrhoea.  The  stools  at  first  are  semi-solid  but  rapidly 
become  liquid,  often  foul  smelling  and  associated  with 
gas.  The  higher  in  the  bowel  the  lesion,  the  more  odor 
and  gas.  The  color  varies  from  a  light  to  a  dark  brown. 
If  the  trouble  exists  in  the  small  bowel  only,  the  stools 
are  firm,  formed,  and  contain  particles  of  hyaline  mucus 


362    CHARACTER  OF  FECES  IN  INTESTINAL  AFFECTIONS. 

visible  only  upon  microscopic  examination.  It  usually 
contains  particles  of  undigested  food.  If  the  colon  is 
affected,  the  stools  are  loose.  Extensive  involvement  of 
the  colon  is  usually  accompanied  by  mucus  un  large 
quantities. 

Chronic  Inflammation  of  the  Intestine. — May  follow 
an  acute  attack  or  may  follow  some  of  the  infectious  dis- 
eases. Diarrhoea  usually  alternates  with  constipation. 
Rarer  are  continuous  diarrhoea  or  constipation.  The 
feces  present  the  same  characteristics  as  the  acute  inflam- 
mations. 

Diphtheritic  Enteritis. — Always  diarrhoea,  often  with 
tenesmus.  Stools  fluid,  with  occasional  passage  of 
formed  feces.  They  consist  mostly  of  pus,  blood  and 
mucus,  and  some  necrotic  tissue  may  be  found. 

Muco-Membranous  Colitis. — No  frequency  in  num- 
ber of  stools;  may  have  constipation.  Stools  are  com- 
posed largely  of  tough  leathery  mucus  which  may  present 
casts  of  the  bowel.  This  may  be  transparent  or  gray  and 
semi-opaque,  or  may  be  brown  (from  fecal  matter),  or 
red  (blood). 

Cholera  Nostras. — An  infectious  disease  affecting 
both  the  stomach  and  bowels.  The  stools  are  first  fecu- 
lant,  but  soon  become  colorless  and  more  and  more  watery 
until  they  resemble  the  so-called  "rice  water"  stools  of 
Asiatic  Cholera,  and  contain  serum  albumin  and  mucin. 

Dysentery. — Stools  are  large  and  frequently  com- 
posed of  pus,  mucus,  and  blood,  fluid  or  semi-fluid,  may 
find  necrotic  masses  of  mucous  membrane. 

Amoebic  Dysentery.— Stools  are  frequent,  fluid,  and 
may  contain  large  amounts  of  mucus,  frequently  stained 


CHARACTER  OF  FECES  IN  INTESTINAL  AFFECTIONS.         363 

with  blood;  reaction  always  alkaline.  Microscopic  ex- 
amination of  the  fresh  mucus  shows  epithelial  and  red 
blood  cells  and  the  amoeba. 

Carcinoma  of  the  Small  Intestine. — The  stools  of 
which  have  no  distinctive  feature. 

Carcinoma  of  the  Rectum  and  Sigmoid  is  taken  up  else- 
where in  this  volume.  (Chapter  XVI.) 


INDEX 


A. 

Abscess,  ano-rectal,  chapter  on 

137,  189,  305,  322 

— classification   138 

— general  etiology  137 

— ischio-rectal 146,  154,  165,  166 

— diagnosis    148 

— etiology 147 

— symptoms     147 

— treatment    149 

— incision    149 

— sub-mucous 142,  154,  166,  617 

— diagnosis    143 

— examination    142 

— symptoms    142 

— treatment    143 

— incision  145 

— sub-tegumentary 140,  154,  165 

— diagnosis    142 

—etiology    141 

— examination     142 

— symptoms    141 

— treatment   144 

— tegumentary   138,  165 

— diagnosis   140 

— etiology    138 

— treatment    140 

ABLER,  L.  H.,  Jr Ill 

Albolene,   liquid,     89,     100    101, 

128,  168,  203,  208,  228,  232,  289 

ALLBUTT    249,  250 

Alligator  forceps 67 

Amoeba   coli    mitis    (see   para- 
sites)     251,  346 

— dysenteriae  (see  parasites) . . 

248,   249,  346 

Anal   canal 18 


Anal   Fissure    (see   Fissure   in 

Ano) 122 

Anal    Fistula     (see    fistula    in 

ano)    152 

Anal     Papilla      (see      Papillae 

anal)     209 

Anatomy,  chapter  on 17 

Anchylostoma    duodenale 352 

ANDREWS 352 

Anemia 40,  181,  314 

Anesthesia  

— local   (see  local  anesthesia) .  295 
— general  (see  nitrous  oxide) . .  158 
Anguillula  intestinalis  (see  par- 
asites)       356 

Animal     parasites     (see     para- 
sites     

Ano-coccygeal    ligament 27 

Anoscope       (see       Hirschman- 
Kelly) 

Anoscope-Hirschman's 62,    156 

Anoscopy    64,  186 

Anus    17 

— dilatation       (see      dilitation- 

sphincter)    18,     20 

— eversion  of  54 

— fissure  of  (see  Fissure) 122 

— ulcer  of  (see  Ulcer) 122 

Appendicostomy    282 

Appendix   vermiform 263 

Appetite,  loss  of 40 

Artery  (see  Frontispiece) 

— hemorrhoidal  inferior 29,     30 

—middle    30,     31 

— superior    30 

— iliac,   internal 31 

— mesenteric,   inferior 30 


365 


366 


INDEX. 


Artery,  pudic,  internal 31 

— sacral,   middle 30 

— vesical     SO 

Atresia  ani  vaginalis 

— complete     74,  76 

— incomplete    75,  76 

Ascaris        lumbricoides        (see 

worms)     349 

Auto-intoxication     40,  98 

AYERS    239 

B. 

BALL,  SIR  CHARLES.. 26,  116,  119 

BECK,  EMIL  G 1G9 

Bismuth  paste  injections 169 

Bleeding 34,   98,   126,  180 

187,  188,  209,  222,  235,  259,  314 
Blood  in  the  stool    (see   bleed- 
ing)       342 

—test    for 332,  342 

—Holland's    344 

— Klunge's    aloin 344 

— Webber's    .- 343 

Bothriocephalus  latus  (see  par- 
asites)      360 

Bougie,  Wales 69,   311,  321 

Bovinine    .v 132,  162 

C. 

Canal,   anal 18,  126 

Cancer,  rectal 36,  181,  188, 

314,  315,  316,  317,   318,  319,  321 
Carcinoma,  rectal  (see  cancer). 

Cauterization  of  hemorrhoids..  191 

— electro  of  hemorrhoids 191 

CETTI    328 

Chloretone 112,    190,  297 

Clamp  and  cautery 204 

Clover's  crutch 56 

Cocain    296 

Coccyx,  examination  of 58,  59 

Colitis    (see   Proctitis   and   sig- 

moiditis)    327 

Colostomy    .  321 


Columns  of  Morgagni 23 

Commissures,  ana'. . . .  .123,  124,  126 
Concretions  (see  impaction).97,  221 
— removal  of  (see  Foreign 

Body)  325,  346 

Condylomata  (see  Warts) 

37,  189,  231 

Congenital  defect 74,  76 

CONLEY,  H.  P 283 

Constipation,  chapter  on 

77,  38,  178,  221,  235,  313- 

— causes  80 

— diagnosis  83 

•—treatment  84 

— rectal  massage 86 

Corrugator  Cutis  Ani 18 

CORSONS,  E.  A 282 

COUNCILMAN  and  LE  FLUER 

239,  248,  258,  263 

CRAIG  269 

CRIPPS,  HARRISON..  .28,  110,  169 

CRISLER,  .1.  A 283 

Cropology  (see  Feces,  exam- 

amination  of)  326 

Cryptitis,  chapter  on 209,  218 

— symptoms  218 

— treatment  219 

Crypts  of  Lieberkuhn 235 

Crypts  of  Morgani 18,  20, 

124,   147,  168,  189,  209,  213,  307 

D. 

Defecation,  disturbances  of 
(see  abscess,  constipation, 
fissure,  hemorrhoids,  im- 
paction,  rectal  valve). 

—physiology    of 78,  326 

DE   VILBISS'    Speculum...  145,  167 

— spray  tube   227 

Diarrhoea    38, 

98,   166,   222,   231,   244,   316,  327 
Diet. 

— in    constipation 81 

— in  dysentery 266 


INDEX. 


567 


Diet,  in  fissure 127 

— in  hemorrhoids 208 

—test    327.  331 

Digestion,    disturbance    of 40 

Digital    examination 48,  135 

Dilatation  of  sphincters 

.54,  104,  130,  186,  193,  199 

— local    anesthesia    for 299 

Discharge    38,     98 

113,   114,   154,  166,   168,  209 
222,  235,  259,  260,  314,  332,  342 

Douglas,    pouch    of 28 

Dysentery,    chapter   on 238 

—distribution    239 

—general    etiology 239 

— history    238 

— acute  catarrhal 243 

— diagnosis    245 

—pathology     243 

— prognosis    245 

— special  etiology    243 

— symptoms    244 

— amoebic     248 

—case    reports 260,  261 

— complications 263 

— diagnosis    264 

— etiology 248 

— pathology    253 

— prognosis    264 

— sequelae    263 

— treatment   265 

—diet    : 266 

— intestinal   antiseptics 270 

— irrigations    274 

—laxatives    269 

— prophylaxis    265 

--remedial    267 

—chronic  amoebic  279 

— diphtheritic    245 

—  complications    247 

— diagnosis    247 

— etiology     246 

— pathology     246 

— symptoms    246 


Dysentery,    treatment 247 

— secondary  diphtheritic 247 

— prognosis    248 

— symptoms     248 

—treatment  248 

E. 

Elevations 37 

Enema    61,  111 

Entamoeba   Histolytica 

248,   250,  252 

Eucain  (see  Local  Anesthesia) 

.....114,   115,  296 

Eversion   of   anus.  .  .  .  .  .  .54,   55,     56 

Exaggerated  lithotomy  position 

: 72,   186 

Exaggerated  Sims'  position 281 

Examination,   Chapter  on... 41,  313 
— abdomino- rectal     (see    Recto- 
abdominal) 57 

— abdomino-vagiual  58 

— anoscopic   (see  Anoscopy) ...     64 

—digital    49,     52 

— of  feces   (see  Feces) 326 

— protoscopic       (see      Proctos- 

copy)    67 

— sigrnoidoscopic  (see  Sigmoid- 

oscopy)    73 

— vagino-rectal    54 

External  Sphincter  (see  Sphinc- 
ter Ani  External) 18 

F. 

Fecal  impaction  97 

Feces    (see   Stools,   defecation)   326 
— character  of  in  intestinal  af- 
fections     301 

— acute  intestinal  catarrh   (see 

Proctitis)    361 

— amoebic  dysentery   (see  Dys- 
entery)     362 

—cholera  nostras 362 

— chronic      intestinal      catarrh 

(see  Proctitis)    362 

• — diphtheritic   enteritis 362 


368 


INDEX. 


Feces  (see  Stools,  Defecation). 
— dysentery     (see    chapter    on 

disentery)    362 

— muco  -  membranous  colitis 

(see    sigmoiditis) 362 

— chemical  examination  of 336 

— fermentation    test 336 

— sublimate    test 336 

— clinical        examination        of, 

Chapter    on 326,  331 

— macroscopic   elements 329 

— misroscopic  elements. 330 

— examination    333 

—normal 326,  327,  328,  329 

— pathologic  elements 332 

— clinical  significance  of  tests.   339 

— concretions  in 346 

— estimation  of  lost  albumen . .  338 

— gallstones  in 345 

— location  of 53 

— parasites  in  (see  Parasites) .   346 

— tests  for  blood  in 344 

— Benzidine    test 344 

—Holland's  test 344 

— Klunge's    test 344 

—Webber's    test 343 

Finger  cot 50 

Fissure  in  ano,  Chapter  on.... 

122,  187,  209,  219,  235,  306,  314 

— after    care 132 

— diagnosis    126 

—etiology    123 

--symptoms    126 

—treatment  126 

— surgical    130 

— excision    133,  134 

— author's   operation 133,  134 

— incision  130 

— multiple    123 

Fistula  in   ano,   Chapter  on... 

142,    146,    152,    306,  323 

— classification  153 

— etiology     152 

— blind  external  .  .  164 


Fistula  in  ano,  diagnosis 166 

— symptoms  166 

— treatment 166 

— blind  internal 166 

— diagnosis  167 

— symptoms  166 

— treatment  167 

— horse  shoe 153 

— multiple  153 

— simple  complete 154 

— after  care 162 

— diagnosis  154 

— symptoms 154 

— treatment  158 

— excision  159 

— author's  operation 160 

— incision  159 

— injection  of  bismuth  paste.  160 

— ligature  operations 162 

— sub-muco-cutaneous  169 

— sub-mucous  168,  169 

— tuberculous  171 

— diagnosis  171 

— symptoms  171 

— treatment  172 

Folds,  Houston's  (see  Rectal 

valves)  22 

Forceps,  alligator 67 

Foreign  body  in  rectum 40,  329 

— local  anesthesia  for  removal 

of  308 

Formalin-Boric  solution 273 

Formulae 90,  108,  109, 

110,     111,     129,     132,     191, 

194,  200,  201,  271,  273,  274,  277 
FRANCK  192 

G. 

Gallstones       (see     Impactions, 

foreign  bodies   345 

GANT,   S.   G 29,   92,  111 

H. 

HAMILTON,   E.   A 114 

HARRIS,  H.  F...239,  256,  275,  282 


INDEX. 


369 


Hemorrhage  (see  Bleeding). 
Hemorrhoidal  arteries  (see  Ar- 
teries— frontispiece)    

29,   30,     31 

— forceps,  author's   196 

— nerves  (see  Nerves) 30,     32 

— veins     (see     Veins  —  frontis- 
piece)        31 

Hemorrhoids,  Chapter  on 

173,  35,  37,  84,  209,  236,  288, 

304,   318,  323 

— classification    175 

— external    175 

— integumentary    175,  178 

— treatment    206 

— thrombotic  175,  176,  183 

— treatment  205,  305 

— varicose    176 

—internal    176,  183 

— general  etiology  177 

— capillary  176 

— granular   176 

— varicose   176,  177 

— diagnosis   184 

— etiology 177 

— symptoms    180 

— treatment  190 

— cautery    191 

— excision   195 

—author's  operation..  .197,  199,  201 

— injection   191 

— palliative   190 

— sub-mucous    excision 203 

— surgical    general    193 

— int  erno-external .  179,  180,  182,  198 

— treatment  198 

HILTON,  white  line  of 22 

HIRSCH,   A 239 

HIRSCHMAN,    L.    J. 

— anoscopes 62,  65,  66,  157,  168 

— bloodless  operation  for  hem- 
orrhoids     197,   199,201 

— blunt  ligature  carrier 198 


HIRSCHMAN,  L.  J. 

— dilating        rectal        massage 

bag    86,     87 

— hemorrhoidal  forceps 196 

— method  of  rectal  massage...     85 
— modification   of  Ball's   opera- 
tion      117 

— operation   for   exision   of   fis- 
tula       160 

— for  excision  of  fissure. . .  .133,  134 
— for  rectal  valvotomy.  .92,  94,  95 

— proctoscopes    70,  92,  308 

— rectal    retractor 197 

— rectal  scissors   94,  168 

— rectal  spray  tube 225 

— sigmoidoscope 73 

— valvotomy    needle 92 

HOLL    27 

Holland's  test 342 

HOUSTON  (see  Rectal  valves)  22 
— folds  of  (see  Rectal  valves)  22 
— valves  of  (see  Rectal  valves)  22 

I 

Ichthyol  

112,  128,  129,  228,  232,  234,  279 
Ilio-coccygeus       (see      Levator 

ani    26 

Impaction  fecal,  Chapter  on. 97,  221 

— causes    97 

— diagnosis    99 

— symptoms 98 

— treatment  99 

Indigestion 222,  231,  259 

Inspection,    External    48 

— internal  (see  Anoscopy,  Proc- 

toscopy,  Sigmoidoscopy)  61,     64 
Instruments — 

— for  anoscopy 64 

— inspection    100 

— local  anesthesia 298 

— office     treatment     of     dysen- 
tery     272 

— proctoscopy   68 

— Sigmoidoscopy 73 


370 


INDEX. 


Instruments — 

— surgical     treatment     of     fis- 
sure    127,  133,  134 

fistula   158,  160,  1G6,  167 

hemorrhoids   191,  199 

pruritus 114,  115;  117 

Intermural     abscess     (see    Ab- 
scess     142 

Internal  Sphincter  (see  Sphinc- 
ter ani,  internal) 22 

Iodide  of  mercury 48 

Ischio-rectal    abscess    (see    Ab- 
scess)    60,  146 

—fossa  28 

Itching  (see  Pruritus  ani 

36,    107,    154,  166 

J 

JELKS,  J.   L 227,  238 

—rectal  tube 227,  232,  274 

K 

KARTULIS    239,  271,  272 

KELLY,    Anoscope    65,     67 

— leg  holder 56 

— sigmoidoscope    73 

KELSEY,    CHARLES 110,191 

Klunge's   test 344 

Knee-elbow  position 63 

Knee-shoulder   position 

63,  67,  186,  278 

KRAMERIA,  extract  of 226,  232 

KRAUSS,   WM 261 

L 

Lancet-Clinic     169 

Lateral    Ligaments 27 

Lateral  position   (see  Sims'  po- 
sition)          51 

LE  ROY,  LOUIS.. 279 

Lesser  Sphincterian  Nerve....     20 

Levator-ani    muscle 24 

LIEBERKAUHN     235,  246 

Ligaments    of   rectum 27 

ligature  carrier,  blunt  pointed, ; 
Author's    .   198 


Ligature   operation   for   Fistula 

(see   Fistula)    162 

Ligature,  rubber    (see  Valvoto- 

my,  Fistula,  Stricture) ....   322 

Light,   Electric   head 43 

Linea-dentata  18,     20 

Lithotomy  position 

55,  56,  58,  100,  144,  148 

Local  anesthesia,  Chapter  on 
295,  20,  54,  100,  114,  117, 
130,  133,  140,  143,  144,  145, 
149,  158,  159,  160,  167,  193,  207 
— amount  of  distension  neces- 
sary for 301 

-  -anesthetics    used 296 

— apparatus  necessary 298 

— limitation  of,  Chapter  on.  ...   312 

— point  of  puncture  for 300 

— position  of  patient  for 299 

—preparation  of  patient  for. . .  29s* 
— technique  for  dilatation  of 

sphincters  under  303 

— operating    for    acute    throm- 

botic  hemorrhoids 305 

— operating   for    external    hem- 
orrhoids    304 

— operating  for  fissure  in  ano. .  306 
— operating  for  fistula  in  ano..  306 
— operating  for  hypertrophy  of 

anal  papillae 307 

— operating  for  hypertrophy  of 

rectal  valves  308 

— operating  for  internal  hemorr- 
hoids       19.3 

— operating    for     peri-anal     ab- 
scesses     305 

— operating  for  posterior  proc- 

totomy    310 

—operating  for  removal  foreign 

bodies    308 

— operating    for    removal    peri- 
anal  growth 309 

Lubricant    ,  .  .  50,  277 


INDEX. 


371 


Lymphatic  glands: 

— inguinal    21 

— lumbar 32 

— pre-sacral  or  post-rectal 32 

Lymphatic  vessels 31 

M 

MAC   MILLAN,  J.   A 85 

Malformations  of  anus,  Congen- 
ital     74,  76 

MARTIN,  T.  C 22,  69,     92 

Marginal  abscess  (see  Abscess, 

sub-tegumentary)    140 

Massage,        Rectal,        Author's 

method  of  85,  101 

MAUREL   327 

MCGREGOR 239 

Menstruation,    Disturbances    of  39 

Methylene    blue 64 

MEYER,  W 282 

Middle   hemorrhoidal   vessels..  27 

Milk  of  Bismuth 64 

Milk  of  Magnesia 64 

MOREST1N     32 

MORGAGNI,  Columns  of 23 

— crypts    of 18,  20.  124 

MUSGRAVE 239,   258,    263,  275 

N 

Nausea    40 

Nerve,  fifth  sacral 20,     32 

— fourth  sacral 21,  32,  116 

— internal  pudic  20 

— lesser  sphincterian 20,     32 

— anesthetization  of 302 

— sixth  sacral 20,     32 

— sympathetic  32 

—third  sacral   20,  32,  116 

Nitrous  oxide 100,  130,  291,  322 

Non-surgical    treatment    of    fis- 
sure       127 

—fistula    162 

— hemorrhoids    190 

— proctitis  and  sigmoiditis  223,  231 


Non-surgical    treatment    of    fis- 
sure,   ulcer 162 

Nux-vomica    .  89 


Obstipation    (see    rectal    valve, 
constipation),  Chapter  on. . 

77,   90,    98,     38 

— etiology     90 

—treatment 92,     93 

Office   treatment   of  rectal  dis- 
eases, Limitations  of 312 

Oil,   White  petroleum    (see   Al- 

bolene)    89 

Operating  room  equipment....     41 

OSLER,  WILLIAM 239,  248,  275 

Oxyuris  vermicularis   (see  par- 
asites, pin  worms) 103,  350 


Pain.. 33,  39,  126,  141,  143,  147, 

154,  182,  235,  244  259 

Palpation,  bimanual 60,  148 

— recto-abdominal 57,     99 

Pancreatin   89,  232,  236 

Papilla,    Anal,    Chapter    on 

209,  20,  189,  211,  214,  307 

— hypertrophy  of 211 

— diagnosis 214 

— examination 214 

— symptoms 217 

—treatment  219,  220,  307 

Parasites 103,  221,  248 

—animal  in  feces 346 

— cestodes 357 

— bothriocephalus  latus  360 

— taenia  nana 360 

— taenia  saginatta    358,  359 

— taenia   solium 348 

— nematodes 350 

— anchlyoptoma  duodenale 352 

— anguillula  intestinalis 356 

— ascaris  lumbricoides 103,  349 


372 


INDEX. 


Parasites,   oxyuris    vermiculars 

(see  pin  worms) 350,  351 

— trichina  spiralis  355 

— trichocephalus  dispar 354 

— uncinaria  Americana 353 

—protozoa 347,  346 

— amoeba  (see  Dystentery) ....   346 

— balantidum  coli 347,  348 

PENNINGTON,  J.  R 92,  169,  170 

Peri-anal  abscess  (see  Abscess)  137 

Peristalsis 24,     78 

Peroxide    of    hydrogen 

64,  100,  109,  157,  282 

Physiology  of  defecation 78,  326 

Piles   (see  Hemorrhoids) 173 

Pin  worms  (see  oxyuris  vermi- 

cularis)    40,  103,  109,  351 

Plicae  transversalis   recti    (see 

rectal  valves)   22 

Polypus,  Chapter  on...  125,  188,  288 

— classification   209 

— diagnosis 210 

— symptoms 209 

— treatment  210 

Position,     Exaggerated     lithot- 
omy   72,  186 

—exaggerated  Sims'  281 

— knee-shoulder  ......63,  67,  186,  278 

— lateral  (see  Sims' 48 

—lithotomy    (see  Lithotomy) . .     55 

— rectal  massage  88 

—squatting  59,     gi 

Posture,   Characteristic   in   rec- 
tal disease  141 

— sitting,  characteristic 45 

Probe   65,  66,  158,  167 

Proctitis,  Chapter  on.. 221,  187,  167 

— acute    221 

diagnosis   223 

etiology    221 

symptoms 222 

treatment  223 

— chronic    .   229 


Proctitis,  atrophic 234 

pathology   234 

symptoms    235 

treatment  236 

— general  etiology  229 

— hypertrophic    230 

diagnosis    231 

pathology   230 

symptoms    230 

treatment  231 

Proctoscope  68,  92,  308 

Proctoscopy  (see  knee-shoulder 

position)... 67,  69,  181,  186,  278 

— without  instruments 68,  99 

Proctotomy,  Local  anesthesia.. 

for    310 

Prolapse    of   anus 284 

Prolapse  of  rectum 

35,  189,  209,  222,  324 

— classification   284 

— concealed  286,  298 

— in  children,  Chapter  on 284 

diagnosis 287 

etiology    286,  287 

prophylaxis    291 

symptoms 297 

treatment  288 

actual  cautery 293 

cauterization   with   nitric 

acid  291,  292 

Prolapsing      internal      hemorr- 
hoids (see  Hemorrhoids) . .  184 

Protrusions    37,  188,  189 

Pruritus      ani      (see     Itching), 

Chapter  on 

102,  126,  165,  183,  218,  231,  235 

— appearance  of  parts  in...  105,  106 

-—characteristics  of 107 

—etiology  102 

—treatment 108 

Ball's  operation   116 

general   surgical  treatment  114 

Hamilton's  operation 114 

Pubo-coccygeus      (see     Levator 

ant)   26 


INDEX. 


373 


Pubo-rectalis  (see  Levator  ani-    26 
Pus    (see    Abscess,    Discharge, 

Fistula,    Proctitis).  .38,    98,342 

Q 
Quadrants    of    anus.. 46 


Record  card  (Author's) 47,  48 

Rectal  (see  Rectum) : 

— chambers    22 

—dressing 114 

— retractor  (Author's  modified)  197 

— scissors,  Author's  angular. . .  94 

— spray   100 

— spray  tube,  Author's 225 

— stricture  (see  Stricture,  Rec- 
tal)    310,  321,  322 

—tube    100,  227,  232,  238,  274 

— ulcer  (see  Ulcer,  rectal) 98 

— valves    22,  23, 

69,  71,  90,  91,  223,  277,  308,  322 

— valvotomy  (see  Valvotomy)..  92 

Recto-abdominal  palpation 57 

Recto-Vesical  pouch 28 

Rectum  (see  rectal)  anatomy  of  20 

— prolapse  of  (see  Prolapse) . .  284 

— relations  of 28 

— ulcer  of'  (see  Ulcer) 98 

Restlessness    40 

Ring  worm   103,  109 

Rubber    ligature    (see    Fistula, 

Proctotomy,    Valvotomy) . .  322 

S 

Sacral  backache. .  .39,  147,  222,  235 

Scabies    103,  109 

SCHMIDT 331 

Scissors,  Author's  angular.. 94,  168 

— sharp,  curved    114 

Scybala    231,  245 

Sentinel  pile  (see  Fissure)  .124.  126 

SHIGA    239,  246 

Sigmoid     colon     (see     Chapter 

XII)    22,  28 


Sigmoiditis 221 

— acute    221 

etiology 221 

symptoms 222 

treatment  223 

— chronic    229 

general  etiology  229 

symptoms    and    treatment 
see  Proctitis,  Chronic)  230,  231 

Sigmoidoscope    73 

Sigmoidoscopy   (see  Exaggerat- 
ed Lithotomy  position) 

73,  99,  186 

Silver,  Nitrate  of.  .112,  129,  234,  279 

bims'   position 48,    51,    87, 

100,  117,  142,  144,  148,  185,  276 

Spasm   34,  142,  255 

Speculum: 

— author's  fenestrated   (see  an- 

oscope)    62,     65 

— bivalve,  rectal 68 

DE  VILBISS 145,  167 

Sphincter  Ani  External  (see  di- 
latation)    18,  124,  150,  216 

— local  anesthesia  for  dilatation 

of    299 

— spasmodic  contraction  of....   142 

Sphincter  ani  internal 22 

Sphincter  recti    (Pubo-rectalis)     26 

Squatting  position   59,     61 

Steele's     Fermentation     appar- 
atus     • 336 

Sterile  Water  anesthesia 297 

Sterilizers,  instrument 44 

STERNBERG   239 

STILES 353 

Stools   (see  Feces) 326 

—altered    39,  361 

STRASBURGER  336 

STRAUSS  327 

Stricture,  Rectal 310,  321,  322 

STRONG    ...239,  246,  258,  263,  275 
Subcutaneous  abscess  (see  Ab- 
scess)  140,  154,  165 


374 


INDEX. 


Submuco-cutaneous  abscess 

(see  Abscess)  142,  154,  168,  167 

Submucous  abscess  (see  Ab- 
scess)   142,  154,  166,  167 

Submucous  tract  (see  Fistula. 

Submucous) 167 

Subtegumentary  abscess  (see 

Abscess)  140,  154,  165 

Suppository  (see  Formulae) . . 

130,  159,  194,  271,  274 

Symbiosis,  Bacteria  of  (see 

Dysentery)  251,  252,255 

Symptoms  calling  for  rectal  ex- 
amination (Chapter  on) . .  33 


U 

Ulcer,  Anal,  Chapter  on 

122,  112,  124,  135,  136,  236,  314 

—excision  of  135..  136 

Ulcer,  rectal 

98,  187,  233,  236,  244,  321 

—amoebic  253,  255 

Uncinaria  Americana  (see  An- 

chylostoma  Duodenale) ....  353 
Urination,  Frequent  painful, 

Disturbances  of 

40,  144,  147,  222 

Uterine  disease 40,  98,  103 


Table,  Operating  42 

Taenia  nana   (see  Parasites) . .   360 
— saginatta  (see  Parasites) ....   858 

— solium   (see  Parasites) 358 

Taka   Diastase 89 

Tampton,  Rectal    85 

TEACHNOR,  W 85 

Technique    of    examination    of 

anus   and   rectum,   Chapter     41 
—of    use    of    local    anesthesia, 

Chapter    on 295 

Tenderness    ..34,  140,  141,  143,  148 
Tenesmus..9S,  235,244,  247,  259,  316 

THEVENOL    . 243 

THOMPSON    26r     27 

Tract,  Submucous  see  (Fistula, 

Submucous)  ••..... 167 

Trichina     Spiralis     (see     Para- 
sites)       355 

Trichocephalus  Dispar  (see  Par- 
asites)       354 

Tuberculous    fistulae    (see   Fis- 
tula)      171 

TURCK,  F.  B 85 

TUTTLE,  J.   P 74,   110, 

137,  226,  230,  232,  234,  239,  282 


Vagina,    discharge   from 103 

Vaginal  rectal  examination....     54 
Valves,  Semi-lunar  (see  Crypts 

of    Morgagni) 208 

— rectal   (see  Rectal  Valves) .  .     22 

Valvotomy,   rectal 90,  283 

— Author's   operation   for 93 

— local  anesthesia  for 308 

— needle 92 

Veins   (see  Frontispiece) 

— inferior    hemorrhoidal 31 

— internal  iliac  31 

—middle   hemorrhoidal 31 

— superior  hemorrhoidal 31 

Vibrator,  mechanical.  .112,  193,  299 

W 

WAGNER,  G.  W 326 

Wales  Bougie 69,  86,  310,  321 

WALLIS,  F.  C 112,  168;  219 

Warts,    Venereal 189 

Wasserman  test  for  syphilis...   236 

Webber's  test 343 

AVEIR,  R 282 

Whitehead  operation   204 

WOODWARD 238,  240 

Worms,    Intestinal     (see    Para- ' 
sites)    40,  103,  348 


Diagnosis  and  Treatment  of 
Diseases  of  Women 


By 

H.  S.  Crossen,  M.  D. 

Clinical    Professor    of    Gynecology,    Medical    Department    Washington    University; 

Gynecologist   to  the  Washington  University   Hospital,  and  Chief  of  the 

Gynecological  Clinic ;  Consulting  Gynecologist  to  the  Bethesda 

Hospital,   St.   Louis   Female   Hospital,  and 

St.   Louis   City   Hospital. 


816  Pages.    700  Illustrations. 

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CONTENTS. 

Chapter  I.       Gynecologic  Examination  Methods. 

Chapter  II.       Gynecologic  Diagnosis. 

Chapter         III.       Gynecologic  Treatment. 

Chapter         IV.       Diseases  of  External  Genitals  and  Vagina. 

Chapter  V.       Lacerations    and    Fistula    of    Pelvic    Floor,    Perineum,    External 

Genitals  and  Vagina. 

Chapter         VI.       Inflammatory   and   Nutritive   Diseases   of  the  Uterus. 

Chapter        VII.       Displacements  of  the  Uterus. 

Chapter      VIII.       Fibromyoma  of  the  Uterus. 

Chapter          IX.       Malignant  Disease  of  the  Uterus. 

Chapter  X.       Pelvic   Inflammation. 

Chapter          XI.      Other  Affections  of  Fallopian  Tubes,  Peritoneum  and  Connective 
Tissue. 

Chapter        XII.       Diseases  of  the  Ovary  and  Parovarium. 

Chapter      XIII.       Malformations. 

Chapter      XIV.       Disturbance  of  Functions. 

Chapter        XV.      Invasion  of  the  Peritoneal  Cavity  for  the  Treatment  of  Gyneco- 
logical Diseases. 

Chapter      XVI.      After-Treatment  of  Operative   Cases. 

Chapter    XVII.       Medico-Legal   Points  in  Gj'necology. 
Appendix — Formulae — Index. 


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Aphoris-ms,  Observations   and  Precepts  on   the  Science  and  Art  of  Pediatrics:     Giving 

the  Practical  Rules  for  Diagnosis  and  Prognosis,  the  Essentials  of  Infant 

Feeding,  and  the  Principles  of  Scientific  Treatment. 

BY 

JOHN  ZAHORSKY,  A.  B.,  M.  D. 

Clinical  Professor  of  Pediatrics,  Washington  University  Medical  Department,  St.  Louis; 
Ex-President    Bethesda    Society;    Attending    Physician   to   the    Bethesda   Found- 
lings' Home;   Member  of  the  American  Medical  Association  and  of  the 
St.  Louis  Academy  of  Science ;  Editor  of  the  St.  Louis  Courier 
of   Medicine ;   Author   of   "Baby   Incubators,"    etc. 

WITH    AN   INTRODUCTION 
BY 

E.  W.  SAUNDERS,  M.  D. 

Professor  of   Diseases  of  Children  and  Clinical   Midwifery,   Washington  University, 

St.  Louis,  Mo. 

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Introduction. 

Part   1. 

General  Rules  of  Diagnosis. 
General  Rules. 
Loss  in  Weight.    Appetite. 
Convulsions. 
Physical   Examination. 
Head  and  Neck. 
Some   Deformities. 
Teeth   and  Gums.       Dentrition. 
The  Enanthemata. 
Vomiting.      Hematemesis. 
Diarrhea. 

Distended  Abdomen. 
Abdominal  Pain. 
Abdominal    Swellings. 
The  Nose  and  Nasopharynx. 
The  Larynx. 

Anomalies  of  Breathing.    Cough. 
The    Lungs. 

The  Heart  and  Circulation. 
The  Urine.     The  Eruptions. 
The   Nervous   System. 
Paralysis. 
Tremor,   Choreiform     Movements. 

ache,  etc. 
Changes  About  the  Eyes. 
Changes  About  the  Ear. 
Clinical   Syndromes. 
Fever.     Chronic  Fever. 
Status  Gastricus. 
The   Typhoid   State. 
Infantile   Atrophy. 
Gastroenteric  Infection,  Diarrhea. 
Chronic  Indigestion  in  Older  Children 
Chronic  Constipation. 
Peritoneal   Irritation. 
Severe  Anemia.     Edena. 


CONTENTS: 

Ascites.     The  Adenoid  Face. 

Acute  Pneumonic  Consolidation. 

Intestinal   Obstruction. 

Nervous  State.     Scrofula. 

Tuberculosis. 

Impending  Heart  Failure. 

The   Syndrome  of  Cerebral  Irritations. 

Golden  Rules  of  Prognosis. 

Part  II. 

Golden    Rules    of    Hygiene   and    Infant 
Feeding. 

The  Nursing  Mother. 
The  Wet  Nurse. 
Artificial  Feeding. 
Feeding  the  Sick. 

Golden  Rules  of  Treatment. 

General  Therapeutics. 

The  Newly  Born. 

Diseases  of  the  Mouth. 

The  Neck  and  Scalp. 

The  Throat. 

The  Respiratory  Organs. 

Gastroenteric  Diseases. 

Rickets  and  Scurvy. 

Heart  and  Circulation. 

The  Blood. 

The  Genito-Urinary  Organs. 

The  Nervous  System. 

Specific  Infectious  Diseases. 

Malaria.     Cerebro-Spinal  Fever. 

Diphtheria.     Intubation. 

Tuberculosis.     Pertussis. 

Mumps.     Septicemia. 

Rheumatism  and  Endocarditis. 

Syphilis.      The    Exanthemata. 

The  Severe  Infectious  Fevers. 

The   Skin. 


Head- 


Formulary. 

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Golden  Rules  of  Surgery 

Aphorisms  Observations  Reflections 

On  the 

Science  and  Art  of  Surgery 

A    Guide   for   Surgeons   and   Those   Who   Would   Become    Surgeons 

By 

Augustus  Charles  Bernays,  A.  M.,  M.  D. 
F.  R.  C.  S.,  England 

Late  Chief  Surgeon  Lutheran  Hospital  and  for  Twenty  Years  Professor  of  Surgery 
and  Anatomy,  St.  Louis,  Mo.,  U.   S.  A. 

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CONTENTS: 

The  Education  of  a  Surgeon.  About   Fees. 

On     Scientific    Communications    to    the  Off  With  the  Cloak  of  Superstition. 

Literature   of   Medicine   and   Surgery.  Inflammation  and  the  Confusion  It  Has 

Science  and  Surgery.  Caused. 


GOLDEN  RULES  OF  SURGERY: 

Asepsis.  Genito-Urinary.  Nose. 

Anesthesia.  Operations.  Goitre. 

Abscesses.  Joints.  Shock. 

Abdomen.  Ear.  Oesophagus. 

Appendicitis.  Erysipelas.  Pelvis. 

Aneurysm.  Gangrene.  Rectum. 

Artery  Bleeding.  Hand  and   Foot.  Spine. 

Burns.  Moist   Dressing.  Throat. 

Breast.  Mouth.  Veins. 

Can  Minor  Surgical  Operations  Be  Done  in  Office? 

Death  Following  Minor  Surgical  Operations. 
Fractures  and  Dislocations.  Therapeutic  Hints. 

Irrigation  Drainage  of  Abdominal  Cavity. 
Minor  Surgical  Operations.  Stomach  and  Intestines. 


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Golden  Rules  of  Dietetics 

By  A.  L.  BENEDICT,  A.  M.,  M.  D. 

Consultant    in    Digestive    Diseases,    City    and    Riverside    Hospitals    and    Attendant 

in  same;  Mercy  Hospital,  Buffalo;   Member  of  the  Academy  of  Medicine 

and    of    American    Gastro-Entrological    Association,    etc.  ; 

Author  of   Practical   Dietetics. 

CONTENTS. 
Part  I. 

Chapter  I.  Physiologic  Chemistry. 

Chapter  II.  Daily  Requirements  of  the  Human  Body. 

Chapter  III.  Standard  Diet  in  Health. 

Chapter  IV.  Quantative  Estimate  of  Diet. 

Chapter  V.  Approximate   Methods   of   Checking   Diet   Weight   and   the 

Excretions. 

Chapter  VI.  Transrnutability  and  Reservation  of   Food. 

Chapter  VII.  Waste  of  Food. 

Chapter  VIII.  Predigestion  of  Food. 

Chapter  IX.  Emergency  Methods  of  Introducing  Nourishment. 

Chapter  X.  Preserved  Foods. 

Chapter  XL  Methods  of  Cooking. 

Chapter  XII.  Compositions   of    Natural   and    Commercial    Foodstuffs. 

Chapter  XIII.  Food  Adjuncts. 

Chapter  XIV.  Purine  Bodies. 

Chapter  XV.  Important   Constituents   of   Foodstuffs. 

Chapter  XVI.  Distinctly  Deleterious  Foodstuffs. 

Chapter  XVII.  General   Hygiene  of  Eating. 

Chapter  XVIII.  Diet  Tests. 

Chapter  XIX.  Condensation  of  Atwater  &  Bryant's  Analysis  of  Foodstuffs. 

Part  II. 

Chapter  I.  Principles  of   Dietetics  According  to   General   Pathologic 

Conditions. 

Chapter  II.  Infant  Feeding. 

Chapter         III.  Diet  in  Critical   Physiologic   Periods. 

Chapter         IV.  Diabetis,  Glycosuria. 

Chapter  V.  Obesity  and   Leanness. 

Chapter         VI.  Chronic   Diseases  of   Nitrogeneous   Metabolism. 

Chapter        VII.  Diseases  of  the  Urinary  Organs. 

Chapter      VIII.  Diseases  of  the  Ductless  Glands. 

Chapter         IX.  Diseases  of  the  Liver. 

Chapter  X.  Diseases  of  the  Pancreas. 

Chapter         XL  Diseases  of  the  Digestive   Organs. 

Chapter        XII.  General  Preversion  of  Digestive  Functions. 

Chapter      XIII.  Functional   Intestinal   Diseases. 

Chapter      XIV.  Organic  Intestinal  Diseases. 

Chapter        XV.  Diseases  of  the   Heart  and   Blood  Vessels. 

Chapter      XVI.  Blood  Diseases. 

Chapter    XVII.  Hemorrhagic   Diseases. 

Chapter  XVIII.  Bone  Diseases. 

Chapter      XIX.  General   Principles  of  Feeding  in  Fevers. 

Chapter        XX.  Infectious   and   Parasite   Diseases. 

Chapter      XXL  Respiratory   Diseases. 

Chapter    XXII.  Skin  Diseases. 

Chapter  XXIII.  Diseases  of  the  Nervous  System. 

Chapter  XXIV.  Surgical  Emergencies  and  Operations. 

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A  VERY 
YOUNG  OVUM  IN  SITU 


Dresden 
Authorized  Translation  By 

W.  H.  VOGT,  A.  M.,  M.  D. 

Obstetrician  and  Gynecologist,  Lutheran  Hospital,  St.  Louis,  Mo. 


65  Pages  Text.    35  Pages  Lithographic  Illustrations  in  Colors 
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Publisher's  Announcement 

The  importance  of  an  understanding  of  embryology  is  becoming  more 
and  more  apparent.  The  student  now  realizes  that  anatomy  is  much 
better  understood — where  it  is  worked  out  from  the  standpoint  of  embry- 
onic development — than  where  it  is  learned  in  its  crude  state  in  the 
dissecting-room.  The  surgeon  realizes  that  he  can  better  grasp  the 
relationship  of  structures  when  he  is  familiar  with  their  formation  from 
the  embryo.  The  scheme  of  development  as  worked  out  by  Leopold 
represents  the  latest  work  along  this  line.  The  work  is  most  scientific 
and  cannot  fail  to  interest  all  who  are  seeking  the  fundamental  truths 
of  embryonic  development. 


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Examination  of  The  Ear 

By 
SELDEN  SPENCER,  A.  B.,  M.  D. 

Instructor  of  Otology  in  the  Washington  University  Medical  Department, 

St.  Louis,  Mo. 

With  an  Introduction 
By 

H.  N.  SPENCER,  M.  D.,  LL.  D. 

Professor  of  Otology,  Medical  Department  Washington  University, 
St.  Louis,  Mo. 

67  PAGES  OF  TEXT 

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12  OTHER  ILLUSTRATIONS 

PRICE  $1.00 

CONTENTS: 

Chapter  I.  Methods  of  Procedure   (General   Consideration). 

Chapter  II.  The   External   Ear. 

Chapter  III.  Diseases  of  the  Canal. 

Chapter  IV.  The  Middle  Ear. 

Chapter  V.  The  Middle  Ear  (Continued),  Non-Suppurative  Conditions. 

Chapter  VI.  The  Middle  Ear   (Continued),  Post-Suppurative   Conditions. 

Chapter  VII.  The  Middle  Ear   (Continued),  Suppurative    Conditions. 

Chapter  VIII.  The  Middle  Ear   (Continued),  Purulent   Otitis   Media. 

Chapter  XL  The  Middle  Ear   (Continued),  Purulent   Otitis   Media. 

Chapter  X.  The  Middle  Ear   (Continued),  Operations    in    Chronic    Purulent 

Otitis  Media. 

Chapter  XL  The  Internal  Ear. 

Chapter  XII.  Hearing  Tests. 

Chapter  XIII.  Ir.tra-Cranial  Complications. 

Chapter  XIV.  Exercises  in  the  Surgical  Anatomy  of  the  Temporal  Bone. 

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Suggestive  Therapeutics, 
Applied  Hypnotism 

and  Psychic  Science 

By  H.  S.  MUNRO,  A.  M.,  M.  D. 

Americus,  Ga. 

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Publisher's  Announcement. 

That  suggestion  is  an  important  factor  in  the  treatment  of  diseases  is  no  longer 
denied  by  those  that  keep  abreast  of  medical  progress.  The  medical  journals  are 
replete  with  articles  from  the  leading  alienists  and  internists  of  this  country.  The 
profession  in  Europe  has  been  alive  to  the  importance  of  this  subject  for  many  years 
and  much  has  been  written  on  it  by  such  men  as  Schofield,  Bernheim,  Forell  and 
Duboise.  These  writings  have  been  in  the  nature  of  research  work  and  have  not 
been  devoted  to  the  practical  application  of  this  branch  of  therapeutics  in  everyday 
practice.  The  book  herein  described  is  designed  to  give  a  practical  working  guide 
to  the  general  practitioner  in  the  application  of  suggestive  therapeutics.  Its  purpose 
is  to  aid  the  profession  in  reaching  a  correct  understanding  of  a  subject  that  has 
been  shrouded  in  mystery  and  used  by  the  quack  and  charlatan  in  many  cases  to 
discredit  scientific  medicine.  The  indorsements  that  have  been  given  the  author  by 
prominent  physicians  and  surgeons  are  the  best  recommendations  the  book  can  have. 

CONTENTS: 

Chapter  I.      Introduction. 

Chapter  II.      Suggestion :    Its  Uses  and  Abuses. 

Chapter  III.  Hypnotism :  A  Demonstration  of  the  Efficiency  of  Suggestion. 
Technique  of  Inducing  the  Hypnotic  State. 

Chapter          IV.      Theory  and   Practice   of   Suggestive   Therapeutics. 

Chapter  V.      Simple    Suggestions,    or    Suggestion    Without    Hypnotism. 

Chapter         VI.      Hypnotic  Suggestive  Therapeutics  Applied  in  Medicine,  Surgery. 

Chapter        VII.      The  Psychological  Factor  in  Obstetrics. 

Chapter      VIII.      Training  the  Subconscious  Self  for  Health  and  Strength. 

Chapter          IX.      Correct   Diagnosis  a   Safeguard   Against  Blunders. 

Chapter  X.      Philosophy  and  Religion  and  Their  Relation  to  Health. 

Chapter  XL  Conservation  of  Energy,  Education  and  Control  of  Emotions. 
Breathing,  Relaxation.  Dietetics,  Exercise,  etc. 

Chapter        XII.      Roughing  It  as  a  Means  of  Health. 

Chapter      XIII.      Are  All   Specialists   Egotists? 

Chapter      XIV.      Pensonality  as  a  Factor  in  Therapeutics. 

Chapter        XV.      Environment :     Its   Influence   in   Therapeutics. 

Chapter      XVI.      Brutality  of   Frankness:    Honesty   Imperative. 

Chapter  XVII.  Physical  and  Mental  Hygiene;  Character  as  a  Resource  of 
Health. 

Chapter  XVIII.      Suggestion  in   Education,  Character  Building,   etc. 

Chapter  XIX.  Moral  Stamina  a  Therapeutic  Power;  The  Higher  Art  in  Thera- 
peutics, and  the  True  Physician. 

Chapter        XX.      Self-Mastery  as  a  Fine  Art. 


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Omaha,  Nebraska. 

New  4th  Edition.        367  Pages.        87  Illustrations.        Price  $2.50. 

Tuberculosis  of  the  Nose  and 

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Denver,  Colorado 

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Diseases  of  the  Skin 

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Formerly  Professor  of  Dermatology  and  Syphilology  in  the  St.  Louis  College  for 

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Society,    of    the    Missouri    State    Medical    Association,    of    the 

American  Medical  Association,  of  the  1st,  2d,  3d,  4th,  5th 

and    6th    International    Dermatological 

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PREFACE 

This  book  is  not  a  treatise.  The  intention  has  been  to  make  of  it  a  practical 
guide  to  the  easy  recognition  of  skin  diseases,  as  well  as  to  their  successful  treat- 
ment. The  remedies  which  have  been  recommended  are  such  as  may  be  found  in 
every  practician's  armamentarium  medicinorum.  No  attempt  has  been  made  to 
write  an  elaborate  work,  but  rather  to  furnish,  in  a  clear,  concise  manner,  just 
that  information  most  desired  by  medical  students  and  general  practitioners. 


TABLE  OF  CONTENTS 


Chapter  I.  The  Skin. 

Chapter  II.  Anatomy. 

Chapter  III.  Physiology. 

Chapter  IV.  Diagnosis. 

Chapter  V.  Etiology. 

Chapter  VI.  Pathology. 

Chapter  VII.  Therapeutics. 


Chapter  VIII.  Prognosis. 

Chapter  IX.  Symptomatology. 

Chapter  X.  Classifications. 

Chapter  XI.  Diet  in   Skin  Diseases. 

Chapter  XII.  Food  Eruptions. 

Chapter  XIII.  Appendix. 


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Chronic    Constipation 

By 

J.  A.  McMillian,  M.  D. 

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1909 
Hirschman,  Louis  J 

Hand  book  of  diseases  of  the  rectu 


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UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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